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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q 1601 E. HAZE T ON AVE., STOCKTON, CA 1 p o Telephone (209) 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' r,(-o (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 46WRules and Regulations of the San Joaquin Local Health District. s " ff 1 Job Address" res s f , City jfDGKTh" Lot Size °fid- PM Owner's Name Address -MOOKt'. RIP Phone Contractor�s� t', Address 000 IVJ RIP License No._Y62-632 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ V 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 Weil Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ) ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump FH.P. �� State Work Done_ i Well Destruction ElWell Diameter .� Sealing Material (top 50') F Depth 4Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-❑-_DESTRUCTION "I No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_T" Commercial_ Other °• 4' t' Numbet of living units: Number of bedrooms Cha atter of soil to a depth of 3 feet' f Water table deptht. SEPTIC TANK �T e/Mf Yp 9 ____ Capacity No. Compartments PKG. TREATMENT PLT- f-) ti `r Method of Disposal E "Distance to nearest: Well Foundation= T j Property Line r y f� t v��•r•!,` 7 � LEACHING LINE /n No. & Length of lines //� Total length/size FILTER BED ❑ Distance to nearest: Well Fo6ndation t Property Line ' _ ' r SEEPAGE PITS � ❑� Depth� •` • ' Size - '-' —_�• Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 call for all required inspections. Complete drawing on reverse side. Signed Title: Q._ r Date: l��Ca FOR DEPARTMENT USE ONLY Application Accepted by Date yr Area • Pit or Grout Inspection by Date Final Inspection by Date D Additional Comments: 11*1121 ,9�zixlG.s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 may, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., A 95201 fit/t2FEES INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. + EH 1324{REV,t i e 51 ��-�V(] ( nom, �� r s ('tj•} f ( EH 14-28 ��l'(J �Y( � d [ 1�V•'1 f