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APPLICATION FOR}PERMIT 'SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED . �% 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. g „ Job Address -� �� •� �� City Lot Size PM µ -Owner's Name -e1_AA1'V_A"� ss !13 �r"� 1 4 Phone " 2 Contractor's Name ' , l icense No. � "/ - ____- Phone " ? -3 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ` . SYSTEM REPAIR ❑ OTHER "❑ ' DISTANCE TO NEAREST: SEPTIC TANK [ SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION, AGRICULTURE WELL; OTHER WELL PITS/SUMPS 14 J INTENDED USE TYPE OF WELL. "PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth " ❑ Eastern Surface Seal Installed by �A p Repair Work Done El Type of Pump:' H.P. State Work Done I F / I� Well Destruction ❑ Well Diameter Sealing Material [top 50') �� 1 ! T Depth _j Filler Material (Below 50') �11 TYPE OF"SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo 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 soil to a'depth'of 3 feet: I Water table depth 3 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t I FILTER BED ❑ Distance to nearest: Well Foundation . Property Line i SEEPAGE PITS ❑' !Depth ° Size Number SUMPS ❑ Distance t6'nearest: Well Foundation Property Line DISPOSAL PONDS' ❑ r 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: "!certify that in the performance of the work for which this permit is issued, I shatl not employ any person in such manner as to become subject to workman's compensation laws of-California." Contractor's 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." 41 The applicant m ca ora r uire mspecti . C plate drawing,on re aid a r Signed X Title: Date: w DEP RTMENT"USE ONLY Application Accepted by �-- Date �J/ /[��(/ VCU(! 'Pit or Grout Inspection by Date Final Inspection by Date :Additional Comments: CI Stk "466-8781 4' .. C7 Lodi 369-3621 ❑ Manteca 823-7104 "L].Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 c w. { "FEE' AMOUNT DUE i AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +EH 13-24(REV,10!631 .EH 14-26 1