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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) 4 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. L, Job Address / 7 �-� City Lot Size / / AC PM Owner's Nam Address�" Phone Z a Contracdaresa5zk7r icense Ng� �" Pho s r TYPE OF WELL/PUM . ANEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION_❑ PUMP INSTALLATIOWD m SYSTEM REPAIR ❑ t =t f OTHER ❑ I _JDISTANCE Tb'NEAREST: SEPTIC TANK _r ASEA INER LINES DISPOSAL FLD. PROP. LINE ^ FOUNDATION � '.AGRICULTURE.WELL ! ''OTHER WELL PITS/SUMPS INTENDED'USE. it T-YPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS 5 w ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of'Well Casing ' ElDomestic/Private 1:1Gravel Packer-- LJ Tracy—Type of Casing � Specifications � ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type'bf'Grout _ I Irrigation _Approx. Depth I 1 Eastern -4 Surface Seal Installed by t Repair Work Done ElType of Pump H.P. State Work bone I ` t Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 t Depth Filler Material (Be w 501 TYPE OF SEPTIC WORK:. NEW INSTALLATIOM1ir REPAIR IADDITION DESTRUCTION {-I (No 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 soileto.a-depth-of 3-feet-. f s.r + 'Water table depth } as- • ��--�,�� 1 SEPTIC TANK'-N ElType/Mfg . 1 Capacity) —. No'..Compartments PKG:k-TREXTMENT PLT. ❑ t 6 '• Method'of Disposal qkr Distance to nearest: Well . _ Foundation Property,Line�..� * LEACHING LINE A x No. & Length of line z— Tote] length/size FILTER BED ' 1❑ Distance to nearest: Well Foundaon •Property Line' 4 r r 1 SEEPAGE PITS Al Depth_ 1?i Size -- f Number er SUMPS Ll Distance to nearest: Well Foundation Property Line "-" ' DISPOSAL PONDS ❑ t �"' tr a # { 1 �"` * 1. I hereby certify that I have prepared'this application and that'the+work-will"6e done in accordance'with San Joaquin county ordinances, state laws, and s rules and regulations of the San Joaquin Local Health District, i # t I Home owner or licensed agent's signature certifies the'foliowing: "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 workrnan�s compensation laws of California.'i Contractor's hiring or sub-contracting signature certifies the following; "I certify that iri the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." l r The applicant must call for all required i spec ons. Comple drawing on reverse side. T r ^.1 �] S. Signed Title: pate; - I yNAt „' �!i R DEPARTMENT USE ONLY k = f , s I Application Accepted by `^ Dat J-V Ilee Area Pit or Grout Inspection by Date T, FinalFinspection by f ' Date Additional Comments: 691,e/ Q /fU /�'9 1 l ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑.Mante823-7 04 ❑ Tracy 835-6385 a s Applicant - Return all copies'4oNEnvironmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 9$201 ; 'f e -1 21—FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY� DATE PERMIT'NO. EH 13'+ EH.�14-2g iREV.1y x 5t' _ ,.1 1' 'fit- t. I-7 _,,,'1 L .. ��`. (; ` /�J o . . _.