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APPLICATION FOR PERMIT SAN JOAQUIN FOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) App4cation is horeby 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 Lural Health District. 1t C Wosq 090 x,�., Job Address _tl_� Q� ^��+ �-� City "Otti Lot Size PM 19wnci's NameL i7\ , �1 C� I 0(0 IM+ AddieJO 6 1 6X 5�Y 7 ST�'�7�4��z�E3J�Phone .-.-.--.––-.- Contractor 's ` Address 7q%? 4,0j%je No:��LZ-Phone 339-1/30 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT L] DESTRUCTION LJ PUMP INSTALLATION .-1 SYSTEM REPAIR Ll OTHER LI / �– DISTANCE TO NEAREST: SEPTIC TANK _ _._ SEWER LINESDISPOSAL FLD,!!!!!� PROP. LINE _--_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ><Open Bottom G Manteca Dia: of Well Excavation. Dia. of Well Casing L1 Domestic/Private C Gravel Pack C Tracy Type of Casing ,p�� _' Specifications i'I Public –I OtherDea F Delta 'Depth of Grout S s Xlrrigation ACapnrox. Depth I : Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. _. Stat Work Done Well Destruction C Well Diam Sealing Material (top 50'1 _ Depth7l Filler Material (Belo TYPE OF SEPTIC WORK: NEW INSTALLATION I I RLPAIMADDITION I I DESTRUCTION I I INo septic system permitted if public Sewer is available within 200 feet.) Installation will serve: Residence_ Commercial__._ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _..._.. .-__ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. Ll Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE C No. &Length o lines --- - Total length/size____ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Site Number SUMPS LI Distance to nearest: Wel Foundation__ Property line i DISPOSAL PONOS U r' 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."Contractors 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 a for all r aired ' spections. plate drawing on reverse side. qq�q Signed X Title: Date: FOR DEPARTMENT-USE ONLY Application Accepted by _ Date :3-22, HCl Area Pit or Grout Inspection by Date Final Inspection by__. !EDate S 3 �c,3 Additional Comments: C Stk 4666781 O Lodi 369-3621 D Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASK CK 4 RECEIVED BY DATE PERMIT NO. .-EH1 3.241REV.1'M4) ��// � EH 14-2a i � J