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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" j 1601 E. HAZE T ON AVE., STOCKTON, CA E Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r v F (Complete in Triplicate) frs 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. ' Job Address � f Ci ST IC>N tY Lot Size PM Owner's Name 11 Address (fid Phone .� _ Contractor Sta A t Address�RWLicense_Flo,_ _Phone �' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEA LL-71PRUBLEM AREA) ^"" CONSTRUCTION-SPECIFICATIONS ❑:Industrial ❑ Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pa&)---VTracY L;�,TR,of Casing Specifications 11 Public ❑ Other D DeltF------"—bepth-of Grout P Seli Type of Grout ❑:Irrigation ---Appx!De th�❑ Eastern Surface Seal Installed by I { Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 50') g i 3 Depth- 1 �....,.F.iller Material (Below 501 i TYPE OF SEPTIC WORK: -NEW INSTALLATION 0 REPAIR',/ADDITION OF DESTRUCTION 0 (No septic system permitted if public sewer is i �---�- z- �---- •-`! available within 200 feet.) Installation will serve. 144sidence-A- Commercial_ Other r j Number of living units: Number of bedrooms. � Character of soil to a depth of 3 feet: aRE 1 - -- _Water table depth ' SEPTIC TANK 9 Type/MfgI 1`7 Capacity -12.01D No. Compartments RE �- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundationt_ �d Property Line �4 i LEACHING LINE El No. & Length of lines r Total le�n`gth1si a FITTER BED Cl Distance to nearest: Well Foundation Property Line q r _ r SEEPAGE PITS ❑l Depth Size Number SUMPS ❑.. Distance to nearest: Well Foundation Property Line .' DISPOSAL PONOS ❑ �;d 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 District. s 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-corhpensation.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." f The applicant must cal! for all required inspections. Complete drawing on reverse side. f , Hn� l Signed Title: Date: - I �_ FOR/�DEPARTMENT USE ONLY Application Accepted by `e Date !J Area F Pit or Grout Inspection b r f Y Date Final Inspection by Date 77 Additional Comments: ❑ Stk 466 6j8f.- ,,a❑„Lodi-369-3621,,,. 0-.Manteca- 823-7104—❑Tracyx835-6385 l Applicant- Return.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201FEE i INFO AMOUNT DUE AMOUNT RENIITTED` c` CASH 'T�� RECEIVED BY DATE PERMIT'NO. + EH 13-24 EH 1428 IREV.t i k sl -70 , 00 MI/ --F3- Z,1^6>(,Pg&- d-Xoo I