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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELiON 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. /// City y �L�VIr� 1 "� .., Lot Size PM Job Address /q ,O �7� ,t .n /"+ E� d/7l !/ -!/�% Address �^/� � Phone i Owner's Namme�ett "�G�((�� f ,ra v ContractoA �Aek- t Address � � �1��sd2�V2 License No. V Phone 'TYPE OF WELL/PUMP: NEW WELL O - WELL REPLACEMENT-0 DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR O t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I-1 Public Fl Other n Delta Depth of Grout Seal Type of Grout 1 I litigation —Approx. Depth I I EasternSurface Seal Installed by Repair Work Done ❑ Type of Pump -H.P. --- State Work Dane Well Destruction ❑ Well Diameter Sealing Material flop 501 Depth Filler Material (Below SO'I /k} • TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted d pubiic sewer is lr available within 200 fast.) Installation will serve: Residence_ Commercial_ Other g/��U J/ r-• Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg - Capacity No. Compartments _PKG..TREATMENT.PLT.O Method of Disposal Distance to rtearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED _ ❑ .Distance to Paarest:- Well, Foundation Property Lim ^v r / SEEPAGE PITS I I Depth Sue Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .0 - --• —,- 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 L rut"and regulations of the San Joaquin Local Health District. (7 Home owner or licensed agent's signature cartifres the following: "I certify that in the performance of the work for which this permit's 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:"I carry that in the.performance of the work for which this permit is issued,I shall employ patterns subject to warkm in's compensa- tion laws of California." The applicant mu "I]for aaIle/)rrepiro insp, . s. Complete drawing on r versa side. Signed K ��y' Title: � •� Date: i- /i!'" FOR ARTMENT USE ONLY ' 7 2� Area Application Accepted by Date / Pit or Grout Inspection by Date Final Inspection b Date 7 Additional Comments: _ l • i O Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Pernh/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED BASH RECEIVED BY DATE PERMIT NO. INFO/ - r EN l}p(REV.V nal v EN 1426