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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)-466-67$1 LIW Sc/2,0 rnr � C PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Local Health District- x 10`7 AO Wak - 1-n= Job Address /� -_ City —\Lot Size PM Owner's Nam.'t�tf�� 9r1 �Jf'f k'k. . Address i' Phone 5 Contractor 15wa .t Address License No. Phone_ TYPE OF WELL/FUMY: - (T----� VvtLL Htr LAUtnn[rv't j u�- u[srlrotir�orv� 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public ❑ Other 17 Delta DepthofxGrout„Seal' Type of Grout I I Itrigation �.-Approx Depth I 1 Eastern Surface Sealy Installed by Repair Work Done 0 Type of Pump H.P. f �� State Work Done _ Well Destruction 0 Well Diameter Sealing Material Itop 50) -Depth - Filler Mate�ialt{Below 50`) �J i TYPE OF SEPTIC WORK: NEW INSTALLATION 11 flEPAIR/ADDITION i I DESTRUCTION Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_� : Commercial Other Number of living units: r. Number of bedrooms ” Character of soil to a depth,of,3 feet: ` Water table depth r~ SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments {r, PKG. TREATMENT PLT. ❑ I + Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance!to nearest: Well Foundation Property Line 4 f SEEPAGE PITS 1 ) Depth 5 Size Number SUMPS 0 Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS❑ 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 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 pertormance of the work for which this permit is issued, I shall employ persons subject to workman's conipansa- tion laws of California." { The applicant must call for all required inspections-Complete drawing on reverse side... X SignedWk"( ,�t,_ -:Title: /�!/ bate: FOR DEPARTMENT USE ONLY 89 Application Application Accepted by Date `�^ `� 4 Area Pit or Grout Inspection b Date F' Inspection b. -' }��_ _ Date Additional Comments: 40 K__S Q Stk 466-6781 a Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5`- ,�- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox-2b09, Stk., CA 9525 01 FEE AMOUNT DUE AMOUNT REMITTEDC S RECEIVED BY DATE PERMWNO. INFO a +.EH13-24(REV.r/x S) EH 14-26 1A r