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APPLICATION FOR PERMIT SAN JOAQUIIN LOCAL HEALTH DISTRICT .4k-- 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone 1209) 466-6781 nr0 � PERMIT EXPIRES 1 YEAR 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 4 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 47 AJ A -Th � r� City �� Lot Size `�� K r�D PM Owner's Name" ] S�> � Address Phone Contractor �rt ALL Address 5 0 r w License No. Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl: DESTRUCTION ❑ 0 PUMP INSTALLATION ❑ r~ --Y* SYSTEM-REPAIR ❑' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES j DISPOSAL FLD. PROP. LINE i FOUNDATION i AGRICULTURE WELL f OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ',.PROBLEIM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ) ; li ❑ Open Bottom ❑ Manteca r 1 Dia. of Well Excavation Dia. of Well Casing (� ❑ Domestic/Private* ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications E� ❑ Public ❑ OtF er ❑ Delta s.� Depth of Grout Seal Type of Grout ❑ Irrigation 1 -Approx. Depth ❑ Eastern Surface Seal Installed iby Repair;Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50') c 1 =� ;! Depth Filler Material (Below 501 TYPE OF SEPTIC:WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION septic system permitted if public sewer is 1 a available within 200 feet.) E Installation will serve: Residence commercial— Other i } A Number of living units: Number of bedrooms Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK i )K Type/Mfg Capacity.` No. Compartments PKG. TREATMENT PLT. ❑ .�� Method of Disposal /�. Distance.to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED YV ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance-to nearest,—Well Foundation Property Line DISPOSAL PONDS ❑ j 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 Sanl.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 emany person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifie 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 o Iifornia." T a licant c I for all quire inspe 'ons m No drawn"on re rse side. Signed A Ti e: �'�J bate: I � FOR DEPARTMENT USE ONLY; Application Accepted by `"' Date JO Area _ "Pit pr Grput Inspection DaFinal Inspectiony --Dat Additional Comments:' ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 83546385 Applicant- Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e1FEE 'INFO (AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. + EH 13-241REV.1/eal 361 (3 <3a6_�7 C 7 EH 1428 •' i i