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t, G APPLICATION FOR PERMIT Q IN LOCAL HEALTH DISTRICT SAN JOA U ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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`andlor install the work herein described. This application is made incompliance 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 DistricLN % /vowJob Address .-___—, � -� /' ,/City,/ Lot Size PM Owner's Name �� .V. !��At� Address //-oo I� ►/ Phone .� 2 Contractor/!// • Address License No. Phone_ TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ 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 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 r i'1 Public Cl Other F] Delta Depth of Grout Seal Type of Grout _ I F I I Irrigation l_..Approx. Depth l I Eastern Surface Seal installed by _ Repair Work,Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing.Material Itop 50') O 1 I Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION-L I' DESTRUCTION (No septic system permitted it public sewer is vailable within 200 feet.) " Installation will serve Residence_ Commercial_ Other Numtier of:living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK P�. ❑# Type/Mfg Capacity '" No. Compartments PKG. TREATMENT PLT. L1 t _ _ Method of Disposal - `1 Distance to nearest: Well Foundation Property.Line LEACHING LINE`Aa ❑ Na. & Length of lines Total length/size FILTEfi'BED r ❑ Distance to_nearest: Well Foundation Property Line , i SEEPAGE PITS ( I Depth Size t* Number �, 4 SUMPS Ll Distance to nearest:r Well Foundation r. Property Line i # DISPOSAL PONDS ❑ f 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 oinhe 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of tHe_wark for which,this permit)issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican�call require inspections. Complete drawing on reverse side. Signer! X �' Title: I FOR DEPARTMENT USE ONLY Application Accepted by 1 Date — Area Pit or Grout Inspection by Date Fin/all Inspection by�/ - per `>< Date 30?� Additional Comments: 1 /2:i�, ZrG es- ,, S:4.1� 1 ❑ Stk, 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies tta: Environmental.Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'No. 14 INFO t' E CASH a.EH 13-241 RE'V.t/n51 �j� .f�� / 0/ 3 .�'O 00, EH 14-26 i* ✓ rr"