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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T OWAVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED " (Complete in Triplicate) t 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 Ordina ce N . 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Y Job Address �� f �''p""City � Lot Size � �► p ? f M y Owner's Name _Sd s a�r /' E Phone ZM G ! Contractor License No. /rJ j Phone+ L. TYPE OF WELL/PUMP:.- r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. �_,PROP. LINE: FOUNDATIONAGRICULTURE WELL OTHER WELL �PITS%SLIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Diar of Well.Casing ❑ Domestic /Private ❑ Gravel'Pac'k r ❑-Tracy Type of Casing Specifications ' 17 Public _ n Other '�r-� F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation �,-Approx• Depth I�icEastern »k "Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work•Done Well Destruction ❑ Well Diameter s� Sealing Material (top 501 f Depth _ Filler Material f Below ! • " �i TYPE OF SEPTIC WORK: NEW INSTALLATION-l'.] REPAIR/ADDITION I DESTRUCTION,I,-1•INo septic system permitted if public sewer is C 'k, available wi in 200 et.! R t Installation-will serve: Residence 'tCommefcia! tither Number of living units: Number of bedrooms _ A: - ( Character of soil to a depth of 3 feet: � € � ^^1� Water table depthF ! SEPTICiTANK ElType/Mfg Capacity .G.... No. Compartments PKG. TREATMENT PLT. ❑ y it X7.1 :Method of D!�Posfl Distance to nearest: Well v �• oundation property Line LEACHING LINE ❑ No. & Length of lines r _ t t li # P 9 — Tot FILTER:BED ❑ Distance to nearest: I F a 'Y i`Property Line f SEEPAGE PITS I I DepthSize Number I — �_— _, - --- u•91b SUMPS L] Distance to nearest: Well * foundation Property Line r DISPOSAL PONDS 0- I i hereby:certify that I have prepared this application and that the work will be don in_accord_a_nce with_Sao.J.oaquin..county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 4 �._ i Home owner or licensed agents 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-manneoas to become subject to workman's co6ensation laws of California.';-Contractor's hiring or sub-contracting signature certifies the following,'.;I c.egifyghat in the perfo�rriance of the work for which this permit is issued,1 shall employ persons su � bject to workman's compensa- tion laws of California." ""�^ i 3 i �a The app41icantst call for all re firedins S,;IQns. Complete tlrawing on reverse side. ik Signed a Title: 5 _ .. ----- _..,_...Date: _. FQR-DEPARTMENT USE ONLY Application Accepted by Datet Area,..W. Pit or out Inspectionby Date _. Final inspection by ;.bte Additional Comments`:,r ; =t cs.Q f Q Stk t466-6781 //❑ Lodi 369-3621 ❑ Manteca 1123-7104 p Tracy 835-63$5 Applicant- Return all copies ;to: Environmental Health Permit/Services 1681 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t° INFO AMOUNT DUE AMOUNT REMITTED 1CASH RECEIVED BY DATE PERMIT'NO. 3 + EH 14-29 EH 134IR 4 EV.F,.�...t ,... .•- ��— —[f,� - -- .._ — .. --•_ - ..,..a.......� `�'+_.,, _�`j'� - � �-. V '� !f t (►� -