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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 a PERMIT EXPIRES 7 YEAR FROM DATE ISSUED . i (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. Job Address 4 r City Lot Size , PM Owner's Name dress L7 /"Phone if, -0 2 .� t1y 3C 2 Contractor I &y/02'*ddressj A License No�&Z�y Phone -9- OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ %SYSTEM REPAIR ❑ s OTHER ❑ DISTAf CE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLb: PROP. LINE FOUNOA.fI`ON •AGRICULTURE WMLL- '*'OTHER WELL-^''""' PITS/SUMPS INTENDED USE TYPE OF WEL! PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1?1 ❑ Industrial ❑ 0 n bottom Manteca Dia. of Well Excavation Dia. of Well Casing ! ❑ Domestic/Private ❑ Grav Pack 0-Tracy T e of Casio t . I If, Y YP g Specifications L� ❑ Public",;, ❑ Other ❑ Delta Depth of Grout Seal f P Type of Grout ❑•Irrigation _.JAppro epth ❑ Eastern Surface'Seal Installed by t ( %RepairiWork Done, ❑ Type of P mp, H.P. 4 State Work Done_ x a =f ` Well-Destruction ❑ Well D'(meter yy 'a .,,._Sealing Material•ftop 50'•l .Dep , } .._ ller Material (Below.50) ---- TYPE OF SEPTIC WORK:% NEW INSTALLATION ❑ REPAI /ADDITION DESTRUCTION ❑'L(No-septic system permitted if public sewer is J P- available within 200 feet.) 6 Installation se v: Residence '""',C�om..mercial_ Other w Numger of liviI. ng units: _ 1NuriibAr'of�bed or oms Character of soil to a depth 1f f� Water table depth SEPTIC TANK ElTy a/Mfg i � Capacity No.'Compartments PKG. TREATMENT PLT. l] lMethod of Do I t Distance to nearest: Well� Foundation Property Line 3 LEACHING E 'l0 No. & Length of lines -�' To al length/size FILTER:BE istance to nearest: Well /✓p�'� Foundation /s Property Line SEEPAGE IT Depth Size N ber SUMPS �[(� Distance to nearest: Well 1k 0 4"<- Foundation Property Line DISPOSALLi7 C 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 tge San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify thatlin 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 compansation laws of California."Contractor's hiring of sub-contracting signature certifies khe 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 a is t must call f .all required inspections.Pp�• q p . Complete drawing on reverse side. s M� j (�i7f Signed Title: 3 �/ -Q : . Date: _ � t FOR DEPARTMENT USE ONLY t Applicat{on Accepted by Date Pit or Grout Inspection by Date Final Inspection IL&Nam Date' >I Additional Comments: 'J fI ❑ Stk 1466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applica - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O.-Box 2000, Stk., CA 95201 t , INF) AMOUNT DUE AMOUNT REMITTED, CK ''E` RECEIVED BY �' `DATE{ I PERMIT NO. - �._� s_' CASH ' r' r + EH 13-24(REV.iiasl EH 1428.` 3/3► gr —Z 3ti, �hc ,