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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (208) 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 ;nstail the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ��©T doll, .q _ City — c�� II'�" - . Lot Size PM Owner's Name _�� `_— —_ Address Phone Contractoi�� '"'^ q�L Address� bfr 9AZZ.- Co.. -:13�i rise No + �"Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION i l PUMP INSTALLATION 0<, SYSTEM REPAIR C) OTHER Li DISTANCE TO NEAREST: SEPTIC TANK _ __. SEWER LINES _ DISPOSAL FLD.. _ PROP. UNE _ — FOUNDATION _- AGRICULTURE WELL ____.—_ OTHER WELL. PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ I)Cndustrial Q Open Bottom ❑ Manteca Dia. of Well Excavation --___ Dia. of Well Casing Li] Domestic/Private CI Gravel Pack (_7 Tracy Type of CasingSpecifications C! Public 1 Other 11 Delta Depth of Grout Seat Type of Grout I Irrigation _.Approx. Depth I I Eastern �Suriace Seul Installed by Repair Work Done Li Type of Pump i � H.P. '��;tI'Q� —__- State Work on Weil Destruction ❑ Well Diameter —_ Sealing Material Itop 501) Depth Filler Material 18elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public suwor is available within 200 feet.) Installation will serve: Residence_ Commercial—_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _Wafer table de-pit SEPTIC TANK ❑ T ype/Mfg !_ Capaci,y_--_— No. Cgrr Property l PKG. TREATMENT PLT. CJ Meeha�fisposal Distance t4 nearest: Well __—_ FoundationLin1{e`��__._'_I_''—__n LEACHING LINE Cl No- & Length of fines — _ —__-- — Total length/size._____.______--_—__________ __-- FILTER BED L Distance io nearest: Weil Foundation_ Property Line - ENVitK51Urv1ETgTAL HEALTH SEEPAGE PITS I I Depth _-- Size____—_._--_—_ Number � '? firlc. SUMPS L.) Distance to nearest: Well —_ Foundation Property Line DISPOSAL PONDS 17 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 San Joaquin Local Health Di?;trict. 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."Contractor's hiring or sub-contracting signature certifies the following: "L 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 must it foA011 required ' spections. Complete drawing on reverse side Signed — Title: --- — -- ----------. Date: FOR D ARTMENT USE ONLY Application Accepted by __— DateArea -- Pit or Grout Inspection by _ —_ Date—_-- Final Inspection by._ ( -Lc— Date 2 Additional Comments: CJ Stk 466-6761 0 Lodi 369-3621 CI Manteca 823.7104 —❑ Trac•,r--835-6385 -- ------- — Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE _ PERMIT�NO. INFO CASH EH 14 2a{REV. 1/.5) S'(./{J CA @H/4 26 ! ,