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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,tSTOCKTON,-CA Telephone (209) 466-6781 _ f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5 4 f .. �.; (Complete in Triplicate). i . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is .made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ ' Job Address S>I .x !`7 W ;t .. . .. k i t _ City Lot Size PM Owner's d�- Ck ` Address +. i7�C � �='` i 1_ _ Phone s7t g� f%'ll Contract 0 AddressP': - . L](p� r ln� I© 1 TYPE OF WELL/PUMP: License No. Phone b- r l NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION 11PUMP INSTALLATION 73 WELL REPAIR ❑ DI AOTHER ❑ NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDiD~USE _ TYPE.O.F_WELL PROBLEM-AREA.,.,..CONS.T-RUCTION-SP-ECI FI CATIONS ❑ Industrial Q Open Bottom Cl Manteca Dia. of Well Excavation O:Domestic/Private' p Gravel Pack Dia- of Well Casing �� ❑ Tracy Type of Casing ❑Public 'I~ p.Other I ❑ Delta Depth of Grout Seal Specifications p Cl irrigation , + Type of Grout ---Approx. Depth EJEas_te_rn . -� Surface Seal Installed b Repair Work'D35e""`E]--Typeof"Pump 3 H Pr -. - y ^' r ° . 4�„ Sta[e Work Done_ i Well Destruction ,—Q] Well-Diameter —Sealing Material (top'50') ! Depth Filler-Material [Belo 50') TYPE OF SEPTIC WORK:. NEW INSTALM:TL AIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is i, ? available with' 200 feet.) installation will serve' Ac sidence er � Number of living units Number o bedrooms' Character of soil to a depth of 3 feet: _ SEPTIC TANK —_ ( t t ,a•F�NWater table depth d Type'/Mfg Capacity o. Compartments PKG. TREATMENT'PLT-OP---I 'i �,-�--+-.-.,-�-,:-�_ 5-7— - ---- -� Metho_dfof Disposal Distance to nearest: Well Foundation Property Line'— LEACHING'LINE ❑ No. & Length"of lines .V. . Total !ength/sizFILTER BED }ek Disfanctoynearest: e Well Foundation Property Line : a SEEPAGE PITS ❑ Depth Size X © Number SUMPS 9--`Distance to_nearest: Woll r Foundation = -.property-Eine-=._s= DISPOSAL PONDS ��-..-❑�- . • • .M',..5-. ..-.,._-�... 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, and rules and regulations!of the San Joaquin Local Health District.' I I Home owner or licensed agent's signature certifies the followin� Y't employ an r g: 'tl.certify that in the performance"of the work for which this permit is issued, I shall not P Y person insuchmannerras,fo.become`isubject to workman s compensation laws of Califorriia:".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." i The applicant must reed call for all ; i _ qrinspections. Complete drawing on reverse side. Signed — - --�..-- --- _ _ Title: - - . _ �..----,Date: ... FOR DEPARTMENVUSE ONLY Application Accepted by ` ( 3 6 �---- ---- --.--- - - _- _Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-8781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEAMOUNT REMITTEDCK INFO CASH RECEIVED BY DATE EPERRMIT'NO. + EH 13-24igEV,iinsl �OW � EH 14-Za .I