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P! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA F11 Telephone (209) 466-6781 PERMIT EXPIRES 7 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. {� ` + Joh Address Sl ev �f1-11i.56--1vP City /1 Lot Size PM Owner's Name t' 7 OPWLJL � Address - �9 Phone Contractor*56X& Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E3 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS F- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications y ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Q irrigation _Approx. Depth ElEastern Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION E--DESTRUCTION ❑ (No septic system permitted it public sewer is available within 200 feet.) f Installation will serve: Residence— Commercial_L_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK ❑ Type/Mfg Capacity S.7 No. Compartments x_ I {y PKG. TREATMENT PLT. 151640V �� `TMethod of Disposal . Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line } F SEEPAGE PITS ❑ Depth Size Number � SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done io 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."Contractor's hiring or sub?contracting signature certifies the following:"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 mustcallfor all required inspections. Complete drawing on reverse side. Si Title: _ '� Date: 0� [._.I g FOR DEPARTMENT USE ONLY Application Accepted Pit or Grout Inspection bY Date Area I (`^ Date Final Inspection by � DateJae � F " Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mar4ca 823-7104 ❑ Tracy 8354M ' Applicant - Return all copies to: Environmental Health Pit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE AMOUNT DUE AMOUNT REyTTED CA9d RECEIVED BY DATE PERMIt•'NO. r�(-�+ INFO ___77 {. 4 !� + Eli 13-24(REV.,,a5) C •.:1 �, - 1 I�L� G (� °r EH 14-26 l