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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE 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 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- 1; lee City Lot Size PM Job Address - Pfione O Address Owner's Name r' G'•1�`/��Phone i.]../ ddress License No.,,..,��,Tr� Contractor DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D L3SYSTEM REPAIR OTHER ED PUMP INSTALLATION SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing l7 Delta Depth of Grout Seal Type of Grout - f'1 Public i l Other _ I I Irrigation Approx. Depth L I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P State Work Done i Well Destruction', ❑ Well Diameter Sealing Material (top 501 - . - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION i a olabpelwithin 200 fee�ifpermublic sewer is 'A Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms`+4 �� {, t. Water table depth Character of soil to a depth of 3 feet: ' Noy Compartments SEPTIC TCapacity TANK ❑ Type/Mfg i r=s- Method of Disposal I PKG. TREATMENT PLT. ❑ + Property One � Distance to nearest: Well "`""^�- Foundation i { Total length/size' f LEACHING LINE ❑ No. & Length of lines Total -p�o'/si �Line i FILTER BED ❑ Distance to nearest: Well Foundation P Y i Number SEEPAGE PITS I 1 Depth Size — L� Distance to nearest: Well Foundation Property Line � � SUMPS ; , DISPOSAL PONDS ❑ i s application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared thi rules and regulations of'the San Joaquin Local Health District. or licensed "I certify that in the performance of the work for which this permit is issued, I shat! not Home owner employ any person iagent's signature certifies the following:n 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." ,f The applicant-must call for all required inspections. Complete drawing on reverse side. `— — Title: _ Date: 4— Signed X - F EP NT USE ONLY 4 r _ !O I Datr� Area v Application Accepted by I'- _ Date Pit or Grout Inspection by Date Final Inspection b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltop Ave., P.O. Box 2009, Stk., CA 95201 " * � - _ r..'•`+1 6.�4` � .�.' -_ _ --..`.ter,--.r^_-..r" ti+..v�%�-�" FEE CK RECEIVED BYf DATE a PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO +.EH13-241REV.I/R5) - �� ✓ _.. EH 14-28 ,;.