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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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../.. f `(/T/✓J{�-/ �,,� Job Address. ` !ruz ` City Lot Size / 70- PM i Address Phone az Owner's Name !! Contractor 4 ress r nse No. 'Phone; 7" TYPE OF WELL/P MP: NEW WE L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -- PUMP INSTALLATION;❑ ' SYSTEM REPAIR El OTHER O . ' DISTANCE TO NEAREST: SEPTIC TANK 't SEWER LINES DISPOSAL FCD._ PROP. LINE FOUNDATION r AGRICULTURE WELL -OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ DomestW Private O Gravel Pack ❑ Tracy Type'of Casing : Specifications [7 Public ❑ Other f ❑ Delta Depth of Grout„Seal Type of Grout---, I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by - `- - Repair Work Done ❑ Type of Pump - HcP< State Work Done_ s Well Destruction ❑ Well Diameter Sealing Material ato;21)50' Depth ' Filler Material (Belo TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION IV DESTRUCTION I'] (No septic system permitted if publlc,_sewer is - 01 1 'available within 200 feet.) Installation will serve: r Residence i Commercial_ that r Number of living units:—4— Number of bedrooms . Character of soil to a depth of 3 feet: i a. Water table depth SEPTIC TANK ❑' Type/Mfg --- -Capacity No" Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line C LEACHING LINE ❑ No. & Length of lines �� Total length/size I t FILTER BED 11 Distance-to nearest: Well Foundation "' Property Line d 1 1 SEE PITS 11 Depth f %e Number SUMPS "' Ll to nearest: Well- Foundation --- Property-Line lazlof _ . 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, ani rules and regulations of the San Joaquin Loca6:Health Di1trict. 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 no employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatun certifies the following:"I certify that in jthe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of California." - 1 - The applicant r�tl t cal r all r ired i tions. Com let on eve se side. Signed X r Titla: __ _.__ _ -.. _ Date: FOR DEPARTMENT USE ONLY Appli tion Accepted by Date — Area rout ns¢eci on by Date Final Inspection by �7 03 ��2 c 5; ADate -GsD�gL Additional Comments: Q}q.*—r 7 ' 13 Stk 466-6781 ❑ Lodi 369-3621 ' ❑ Manteca 823-7104 ❑ Tracy 835-63a6 a IT�7_4! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 ry / FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO. NFO t�Q ♦.EN 1121 raw 1/x41 �� , EN 1126