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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 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. City Lot Size PM Job Address % Phone r Address A Owner's Name . , ` • ' `, - (,/ �J �TLscenseTlVo.7 Phone / ' " Co'ntracto� - Address- TYPE OF WELL/PUMP T NEW ELL D WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTE REPAI -❑ OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES pISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS _ r � f INTENDED USE TYPE OF WELL PROBLEM AREA CONST UCTION SPECIFICATIONS Dia of Well Casing ` k ❑ Industrial ❑ Open Bottom © Manteca Dia Well Excavation r j e of Casing— D J ❑ Domestic/Private ❑ Gravel Pack D Tracy ''d , p Type of Grout_ - - -�[l"Delia^ De hof Grout Seal T A � —� - l`] Public f-1 Other t r ,•"� � .� Approx.-Depth I ! Eastern 5 rface Seal Installed by I I Irrigation — t State Work Done l Repair Work Done ❑ Type of Pump I H P;` 1 + �Seali Material (top 50') -- I Well Destruction ❑ Well Diameterf g I t Oepth�- Fiber Material [Below 50'I 1 TYPE OF SEPTIC WORK: NEW INSTAL .s� -REPAIR l I DESTRUCTION I 1 availabpe!w thin 200 feet.1,,,A t public sewer is / Installation will serve: Residence_"F Comm rcial. er th Nurriber of�li wing units: Number of bedrooms( Water table depth Character of soil to a depth of 3-Jeer: L � _ Capacity Z�� No. Compartments ` SEPTIC TANK ❑ Type/Mfg - Method of Disposal , �PKGJTREATMENT PLT.^❑ _ Distance to nearest:; Well Foundation Property Line Tot length/ ize-- LEACHING LINE_ ❑ No. & Length of lines i Foundation Property Line FILTER BED ❑ Dd"ttance,to nearest: Well �-. , Vi _ Number " SEEPAGE PITS 4 1,1 Depth Size SUMPS Cl .Dista ce to n rest: Well Foundation � 1'Property Line fiii"' .,' DISPOSAL PONDS Q � : !fiereby certify that I have prepared this application and that the work vviil be done in accordance with San Joaquin-county ordinances, state caws, 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 shah 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,f I,c4tify that in the performance of the work for which this permit is issued, I shall employ persons subjectto workman's compensa tion laws of California.' • f S "'` �/ The applicant ust.&all.for a I required i spections. Complete drawirig,on reverse side. Signed X f Title: r Dal.. „ '�` R DEPARTMENT USE ONLY - l Area Application Accepted by Date I'-- ri I „ /1 DateV 1 Pit or Grout-inspection by Date Final Inspection by f i r Additional Comments: t r l 466-6781 ❑ Lo L3 Stk di 369-3621 ❑ Manteca 823-7104 C3Tracy 835-6385 # Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009• Stk., CA 95201 ic t r + FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ` DATE PERMITr�NCO. v INFO :..- p '6/D cJ 3 -•--T .. y 4--^— .EHsr—A.�.w�R,.-.�.''ar^'^, EH 14-28 t . fI