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APPLICATION FOR PERMIT v SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ttj e-S ,,,e d4omplete in Triplicate) 1.. 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. � -C _ / -t� 7 I u Job Addressu � City Lat Size PM L Add ss Phone Owner's Name P/ +... 1' Contractor's Name rcense No. Zi Phone 17 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ u DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i..r EI Industrial ❑ Open Bottom I-] MantecaDia. of Well Excavation Dia. of Wel asrng ❑ Domestic/Private ❑ Grave! Pack ❑Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout '–' ❑ Irrigation --Apprcx. Depth ❑ Eastern Surface Seal"Installed by Repair Work Done Cl Type of Pump H.P. State Work Done j Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' ' available within 200 feet_) installation will serve: Residence� Commercial_ Other l Number of living units: J— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ANSEPTIC TANK Type/Mfg Capacity No. Compartments r... PKG.TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well f 00 Foundation r - Property Line (r LEACHING LINE No- & Length of lines Total length/size , J w..r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE.PITS > Depth Size 'e� Number 13 1 � + SUMPS ❑ Distance to nearest: Well�d.i�9._ Foundation c3 0 Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work-will 6 done in accprdance 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:"'1 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 taws of California." w+ The applicant m all requir Spec tons; Compl a drawing on r eise side. (�' y i (Y Signed X 1 f 1� 3�_ Title: / Date: FOR DEPARTMENT USE ONLY rr... f2 Ap lication Accepted by Date h Area Grorlt'lnspection by '�- Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3611 ❑ Manteca 823-7104 ❑Tracy 835-5385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 v FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH t EH 13-241R_EV..101891 JJ S— _:- .. .' e '/23 1/� g5 5-77 rf... EH 1425 ,- - -