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APPLICATION FOR PERMIT ` � SAN JOAQUIN4 LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,;STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED . . , t ..t, . _ ,. .-.,.. (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. 1,862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - - 2 •fit. _. � ,... . - t n � .. Job Address ✓ P PT�,-�._ City _ Lot Size �C YFCyM' Owner's Na/me��'R`��,11� �1� Address.- —S;la Imo. _ Phone Contractor ••,`� bf- - Address��[J -:l'r _ _License�No'. 1 D Phone s /Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ --^—INTENDED-USE—^-STYPE-OF-WELL—PROBLEM AREA-• CONSTRUCYON;SPECinII`A ION - ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ a _ Specifications - ❑ Public ❑ Other ❑ Deka Depth of Grout Seal• / - Type of Grout ❑ Irrigation ____Apjrox. Depth ELWtam Surface Seal Insialkid'by" Repair Work Done ❑ Type of Pump H.P. ) State Work Done Well Destruction ❑ Well Diameter _^ Lild � Sealing Materiel (top 50.1 Depth__`i ! '1 !n Filler Material !Below 50'1 t TYPE OF SEPTIC WORK: NEW INSTALLATION .�.JIEncn.)AIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted it public sewer is - I - available'within 200 feet.) Installation will serve: Residence_ Commercial—L--15t-her ) _ Number of living units: Number ofrooms pta�d Character of soil to a depth of 3 feet �-�t.+0 _Water table depth l SEPTIC TANK Q"fype/Mfg �(.F f Fi�G ) Ca No.No. Compartments 1 PKG. TREATMENT PLT.❑, - Method of Disposal _ Distance to nearest: Well Foundation Property Line _ J LEACHING LINE rl^-lilo. &Length of lines ` Total length/size FILTER BED - I ❑ Distance to nearest Well - Foutdatbn I Property Lina SEEPAGE PITS f ❑ Deptha - r Number ! !/ r SUMPS b/bietance to nsereM: _1/ Fo.nPation Property Lined DISPOSAL PONDS O r tiij•t `., j4 i r I hereby certify that I have prepared this application and that the work will be-done in accordance wit San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i _-f p Home owner or licensed agent's signature certifies the following: "I certify that in the performance of-theavorkJorwh)chthis permit is issued, I shall not employ any person in such manner as to become subject to workman's mm P pensationJawsnflalifomia._rCdntracto/s hiring or sub-contracting signature car the following: '"I certify that in the Performance of the work for which this permit is issued, I shall amploy�p r ons subject to workman's compansa from la 1 Cal'rfornia." I The applicant ust call for II re fired i pactns. m_plete drawing onf area ei - Signed Title: I Date�_rt__p�--• I FOR DEPARTMENT USE ONLY r \� APplicet)on Accepted bi C4 An; Data Pit or Grout Inspectioniby Dere i.+-r Finll Inspection by Additional Comma lttc - + " .`! ❑ Stk 466-6781 ❑ Lodi 3613621 ❑ Manteca 823-7100 ❑ Tracy 935-6M5 .. -+-Applitanf- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA gSlol - I 1 FEEAMOUNT OVEJ��;NT.RE,,MITTED�',[! RECEI INFOVED BY GATE PERMONOa.110oto