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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZEL T ON AVE.,.STOCKTON, CA Teleph"one 12091 466-6781 :PERMIT EXPIRES:'l YEAR FROM DATE ISSUED k I. (Complete.in Triplicate). 'iIla Application is heieby 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 Distri c t" , tq 3; w. ITT- J a �, F city Lot Size �� s� PM Job Address , � . a r �/ 1 Owner's Name Address d 1. 9 '� _ Phone Contractor Address License No. Phone TYPE OF WELL/PUMP. NEW WtLL ❑ WELL REPLACEMENT ❑ DESTRUCTION 171 `I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE Td"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 Q ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s T e of Specifications ❑-Domestic/Private ❑ Gravel Pack ❑ Tracy yP Casing— LI:Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ` —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑'I Type of Pump H.P. State Work Done F Sealing Material Ito 50'l Well Destruction. � '❑ Well Diameter 9 p `*" } Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Iff REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 5 Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feet: A Water table.depth Y SEPTIC TANK El. Type/Mfg Ir Capacity�L Noe Compartments } 1 }g ' PKG. TREATMENT PLT. ❑ Method of Dispa?al A�I , �f� � ..f– Distance to nearest: Well� Foundation' Property Line LEACHING LINE ❑ No. & Length of lines �T Total length/size FILTER BED ❑' Distance to nearest: Well Foundation 2, Property Line_ a i SEEPAGE PITS ElDepth Size Number_ SUMPS ❑ Distance to nearest Well Foundation _ Property tine DISPOSAL PONDS ❑ I hereby certify that 1 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 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 compensa- tion laws of California." The:pplic must call for all requi inspecti ns. Complete drawing on reverse side.Title: Date:Signd X i FOR DEPARTMENT USE ONLY t i r A Iication Accepted by Date Z- c� {i Area Pit Grout Inspection by Date_�-1�'05� Final Inspection by Myn 5�.�1, Date'L�' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CJ,Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 0; _ FEE,. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. "INFO + EH 13-241REV-1/H5). ~ / ci, oz> EH 1428 - -