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APPLICATION,�FOR,PERMIT g f w SAN JOAQUINsLOCAL.HEALTH DISTRICT " 1601 E. HAZEL T ON AVE., STOCKTON, CA �,�► Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - (Complete in Triplicate) �r L�,, e Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here( n edflfM pl(c ion is made in compliance with Sart Joaquin County Ordinance No.549 for sewage or No. 1062 for well/pump and the Rules and Regulations of the San Joaquin Local Health District'. "# Job Address / Va City Lot.Size — PM Owner's Name Address 1 C� + �' �• i fs'-r-*�•��_ Phone -�r Phone 1S.. Contractor's Name License No. TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _,4pprox. Denth ❑ Eastern Surface Seal Installed by— r on Repair Work Done L3 Type State Work De Type of Pump Well Destruction ❑ Well Diameter Sealing Material (tap 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noavaseptic systemithin permitted if public sewer is (� Installation will serve: Residence— Commercial— Other Iii Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: _Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (� PKG. TREATMENT PLT. ❑ �s Method of Disposal 11 d"iy F' { O�stance to nearest: Weilr ( Foundation Property Line -• LEACHING LINE �❑ No. & Length of lines Total lengthlsize FILTER BED ❑ 'Distance to'nearest! Well: -t FoundationProperty Line ' \ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line � DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. , Home owner or licensed agent's signature certifies the following: "I certify that in the,performanoe of the work for which this permit is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applican mut or all required inspections. Complete drawing on reverse side. Signed )C —ter t Title: —/�(,��`'^-1� Date: FOR iPARTMENt�-USE ONLY Application Accepted by Date Area Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 023-7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. INFO +£H 1324(REV.10163) 5. b SSS -- '-'ll,•©H EH 1426