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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 1 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. . 0= �� S7— City AfAJ Lot Size PM Job Address Owner's Name 10546 AAA -DAddress,. Phone Contractor's Name P 'F4000D License No. �G�,:'� Phone �J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ vim' DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing y ❑ Domestic/Private-{ ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout C1 ❑ Public ❑ Other ❑ Delta , Depth of Grout Seal Type of Grout ❑ Irrigatloh ��Approx. Depth ❑ Eastern '. Surface Seal Installed by Repair Work Done ❑ Type of,Pump ` H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 541 =Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRJADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 204 feet.) Installation will serve: Residence'f Commercial Other Number of living units: Number of bedrooms _ T j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i r I Capacity___L_ No. Compartments - PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line W" 1 LEACHING LINE No. & Length of line C111 'i 2 Total length/size s Z FILTER BED ❑ Distance to nearest: Well Foundation Z- z Property Line SEEPAGE PITS Depth � Size�:3 Number r� SUMPS ❑ Distance to-nearest:— Well `� Foundation:� Property Line�— DISPOSAL PONDS ❑ I - ' - . '-` I hereby certify that I have prepared this applicatidn 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 II required inspection omplete drawing on reverse side. ! Signed Title: i Date: I&IFOR DEPARTMENT USE ONLYApplication Accepted by - Date Area Pit or Grout Inspection byte Final Inspection by r Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE R AMOUNT REMITTED CASH RECEIVED SY DATE PERMIT NO. INFO }� �{� + EH 1324(REV.101831 Co O •' -•r ,/.► -_ •. .- w..- �. �C(,J f"� ?Lf-1267 EH 14280!1 _ .