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APPLICATION FOR PERMIT =L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,,STOCKTON, CA Telephone (209} 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED r (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Tics 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. 1 Job Address 62-50V4 ��'�C� ',/ .. x Citys'YL t Lot Size PM Owner's NarnIPVZnJallAddress Phone s6K �! P Contrac r /iCLd Address ,6, i? r License NoI20 z z�p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0•tw.. i SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' �! DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE 1NELL` C OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONS,TRL1CT10N SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.`'of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ca'ng ti Specifications O Public ❑ Other ❑ Delta Depth of Grout Seal', - Type of Grout ❑ Irrigation ��4pprox. Depth ❑ Eastern RSurface Seal Installed by Repair Work Done ❑ Type of Pump H.P�, 10'16tate Work Done_ Well Destruction ❑ Well Diameter Sealing Mateiial ft p,50'1_ Depth Filler Material (Below 501, TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION,❑ DESTRUCTION ❑-INo'septic system permitted if public sewer is f/f available within 200 feet.) N Installation will serve: Residence Commercial ther 4 i Number of living units: Number of be rooms Character of soil to a depth of 3 feet: Water table depth 5 SEPTIC TANK Type/Mfg L Capacity_&n s n Q0 No. Compartments PKG. TREATMENT PLT. ❑ r I i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �No. &;Length of lines 3 Total length/sizeL � FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth h�r -Size f�l - Number SUMPS � Distance to nearest: Well - - Foundation Property Line DISPOSAL PONDS ❑ 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 s rules and regulations of the San Joaquin Local Health District:-/ ,k! Home owner or licensed agent's signature certifies theJollowing: "I certify that in the performance 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 hiringor sub-contracting signature 9 ,.. certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ person's subject to workman's compensa- tion laws of Californi The applicantcall for all uired 'ns ' \ pections. Complete drawing on reverse side i I _ Signed X 'E Title: Date r { V FOR DEPARTMENT USE ONLY 3 Application Accepted by Date C; Pit o�out inspection 6y Date Final Inspection by Dat ( � i Additional Comments: 3 1 ❑ Stk -466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. EH 1426 + EH 13-24IREV.5iy51 t � fJ