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fI APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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. Job Address m City Lot Size PM Owner's Name Lt',G� Address OS / 'o-46-" Phone 4 y! Contracto Address7-1,- ;7 3 Z$'' 2� �� a`- C� 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 WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF0ELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing b ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications 1 7 Public ❑ Other F1 to Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth 1 Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Hone Well Destruction ❑ Well Dia er Sealing Material (top 50') Dep Filler Material IBelow 501 TYPE OF SEPTIC WORK; qqEW INSTALLATION I1 R[.-('AIH/ADDITION DESTRUCTION l I (No septic system permitted it public sewer is Installation will serve: Residence Lx available within Commercial_ Other a Number of living units: __L_ Number of bedrooms Character of soil to a depth of 3 feet: " Water table depth e7o SEPTIC TANK E Type/Mfg Capacity—f op _ No. Compartments �— PKG. TREATMENT PLT" ❑ Method of Disposal Distance.to nearest: Well o Foundation Property Line "✓ r LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS - ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di§trict. 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's compensa- tion laws of California." The applicant must c 1 for all required inspections..Complete drawing on reverse side. I t Signed X W` Title: f �J _ Date: k / FOR DEPARTMENT USE ONLY i Application Accepted by Date / / Area Z— I i Pit or Grout Inspection by Daze Final Inspection by Date 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, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFP AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t i N 51 .Q - 00 -7 )E) gym 1 597