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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,-STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :r t, -(Complete in Triplicate) 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thos 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. k " Job Address 10 1 lV� � Cit 4� Lot Size _ PM Owner's NameiL1 (Q �� Address PhoneTl 97 b_ �� u�ta(� 11 -BIOS 'Contract Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP IN ELATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RE WELL OTHER WELL PITS/SUMPS s I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO TIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: of Well Casing i I ❑ Domestic/Private' ❑ Graver Pack 0 Tracy Type of Casing �cifications ' ti Cl Public - d ❑ Other ❑ Delta Depth of Grout Seal Type-of Grout r s' ❑ Irrigation :e --Approx. Depth Q Eastern Surface Seal Installed by 11 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction. ❑ Well Diameter _Sealing.Material Itop 501 t Depth Filler Material,(Below 501 TYPE OF SEPTIC'WORK: NEW INSTALLATION VREPAIR/ADDITION ❑ DESTRUCTION ❑.(No septic system permitted if public sewer is �1 available within 200 feet., ' ! Installation will serve: Residence Commercial= 'pther Number of living units: __L— Number of b r ours r Character of soiltoa depth of 3 feet r ;. W ter table depth (1 SEPTIC TANK r LR*�Type/Mfg "�� ' Capacity 06_ Ni Compartments PKG;,TREATMENT PLT. ❑ r ! `' Method of Disposal rj- Property Line Distance to nearest: Well�� Foundation �.. -�_ LEACHING LINE n_P:N,:&'.Length_of-lines--- A Total length/size X FILTER BED ❑ Distance toynearest: Well /�! -r! J � �� S,�'_ Foundation_/� Property Line SEEPAGE PITS Depth Size J _ Number SUMPS ❑ Distance to nearest:_-Well elle Foundation Property Property Line DISPOSALt PONDS ❑ 1 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., 1-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 fallowing: "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 applicant usi cal�foralll qui- inspectionsvCbmplefe drawing on reverse side. Signed X `- _ t �. g . .: Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date 417 Area Pit or Grout Inspection by ZjkDate Final Inspection by Date 4. i Additional Comments: TZ O 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 FEEt INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 241REV.iiasl W EH 14-29