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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL'TON AVE.,.STOCKTON, CA _Telephone (209) 466-6781 PERMIT EXPIRES) YEAR FROM.DATE ISSUED { It " r,.,:, ' {tet N; {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 i `Local Health District. k Job Address � � - I City Lot Size PM ' Owner's Name Address �� .5� f,��Q r'w j,�Phone "'7 Contractor Address f TYPE OF WELL/PUMP: License No. Phone t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ElSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USEPiTS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrialr ----❑ Open`Bottom---_. ❑-Manteca-- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy bra. of Weil-Excavatian �_.. _,-Diat"of Well Casing ❑ Public ❑ Other Type of Casing Spetcifications ❑ Delia Depth of Grout Seal ❑ Irrigation --Approx. Depth ❑ Eastern Type of Grout Ii Repair Work Done ❑ Type of Pump Surface by H.P. t - +•Sta a-1Nork bone \� Well Destruction ❑ Well Diameter ; V Sealing Material flop 50'I Depth Filler Material (Below 50') W TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑t DESTRUCTION 1 N septic system permitted if public sewer is S3ailable within 200 feet.) I Installation will serve: Residence— Commercial_ Other 4 Number of living units: Number of bedrooms t 4 Character of soil to a depth of 3 feet: } - SEPTIC TANK ❑ Type/Mfg . (Nater table depth_ PKG. TREATMENT PLT. CI Capacity No Compartments i { Method of Disposal Distance to nearest: Well - r Foundation, .- Property Line-",-- 6 LEACHING LINE ❑ No. & Length of lines t FILTER eED Total IengtFi/size x ❑ Distance to nearest: Well Foundation ►, =Property Line 4 SEEPAGE PITS ❑ Depth Size Number SUMPS i ❑ Distance to nearest: Well Foundation j DISPOSAL-PONDS 11Property Line a 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. Home owne-r'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." 111 The applica st call for all quire 'i pectin . Complete drawing on rever�j side. Signed X Title: Date: : /q�7 ` FOR DEPARTMENT Application Accepted by Date Area Pit or Grout Inspection by f Date—�� Final Inspection by pee' Additional Comments: re i®LA-S r -�- OZ ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 / ❑ Tracy Ave. 65 i%� t Applicant- Return all copies to: Environme I Health P rmit/Se 1 1 E. Hazelton Ave., .O. Box 2009, Stk., CA 95201 � t. } lsr.�-P , FEE_ AMOUNT,DUE + � INFO' �"' �__•- ,AMOUNT REMITTED CASH RECEIVED BY DATE �,�(1 r+ /) ,'1 + EH 13-24(REV.-,iesr - ' f VO��j EH 1429 �" (