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APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA O p M Telephone (209) 466-6781 G(a L.J. , U RIC 0/_ 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 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. 7 Job Address �O Ci Lot Size PM Owner's Name Address N` r� /Y�'r,/ L�iT�/ f��1J Phone Contractor Address yd License No.42 Phone .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST": SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE " TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t*w. ❑.Industrial El Open Bottom CManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f7,.Public "" 17 Other �71 Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth { 1 Eastern ,Surface Seal Installed by _ Repair Work Done L1 Type of Pump H.P. State Work Done Well Destruction E� Well Diameter Sealing Material (top 501 w I Depth filter Material i8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION !if REPAIR/ADDITION # I DESTRUCTION i I (No septic system permitted if public sewer is j A, available within 200 feet.) Installation will serve: Residence_L Commercial Other r Number of living units: —1— Num6er of bedrooms Character of soil to a depth of 3 feet: Water table depth I :SEPTIC TANK ❑ Type/Mfg � Capacity No. Compartments ,PKG. TREATMENT PLT. ❑ 'Method of Dirl u :I Distance to nearest: Well/ Foundation Property Line 'f� LEACHING LINE ❑ No. & Length of lines - `Total length/size07 Q FILTER BED i' ❑ .Distance to nearest: Well � Foundation Property Line EEPAGE PIT c' l I Depth Size ,..,,._._.. Number 1 L1 Distance to nearest:. Well Foundation Q C? Property Line ,� DISPOSAL PONDS '' ❑ i .rr 1 hereby certify that I neve 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."Contractoes hiring or sub-contracting signature certifies the following: '1 certify that in the performance of the work for iy4hich this permit is issued. I shall employ persons subject to workman's compensa- tion laws of California." :,The applicant must call for all r rr inspections. mplete drawing on verse side. Signed Tide: Date: ai FOR DEPARTMENT USE ONLY # Application Accepted by .�...��_ F -_— Date Y` Area i ' Pit or Grout Inspection by Date Y Final Inspection by `1 tE.-t1'�1C G- Date Additional Comments: .❑ Stk 466-6781 -1 0 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 9&Wl' FEE INFO .!h AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. .'.EH 13.24 IREV.i i H 5 r - •'i' ,y ,✓ t .,.�. ./'L - ,� +....., - - �. � /J !✓T EH 1a-26