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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone {2091 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (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. 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. (� r Job Address 0� G�G—�?/q City t Lot Size PM Owner's Name C 49It -„06&A-5— Address 3� "e,L W Phone Contractor c,G Address License No. Y�7 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ D TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE WELL PROBLE CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grav c E1 Tracy Type si Specifications f'l Public Other f 1 Delta Depth of Grout Seal Type of Grout I i Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work bone ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material ?top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION U^o septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg Capacity4 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t \\ LEACHING LINE Cl No. & Length of lines s Total length/size FILTER BED ❑ Distance to nearest: WellFaundationi i Property Line'i SEEPAGE PITS I 1 Depth Size* i Number SUMPS D 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, and 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 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 hiring or sub-contracting signature certifies the following: "1 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." r The applicant ust call for all required inspections. Complete drawing on reverse side. Signed X w TRW _ Aa e..-eDate: FOR DEPARTMENT USE ONLY Application Accepted b Date �V Area Pit or Grout Inspection Date Final Inspection by Datet Additional Comment ❑ Stk 466-6781 TO Lodi 369-3621 ❑ Mant ca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTfED� C K RECEIVED BY f DATE PERMIT'NO. + EH 13-241REV.1/x57 :;5s EH 1 � Ito- 429