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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES V 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. �l Job Address City`� Lot Size PM c �JG2.C� psZ- -S (a [ f LT �2 Owner's Name Address ,h Phone Contractor Address 4 t5�;& License N)G �1_3 2`3 Phone 96 OIX TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © :, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ''SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 61 Domestic/Private ❑ Gravel Pack j ❑ Trac Type of Casio Tracy yp g•-�� ? r� � Specifications -F- - `--- .------ f'1 Public f].Other 171Oelta Depth of Grout Seal Type of Grout-- I rout I I Irrigation _--Approx. Deptb I I Eastern Surface Seal Installed by Repair Work Done G2' Type of Pump , H.P. State Work Done Well Destruction ❑ Well Diameter ( T3 Sealing Material (top 501 Depth Filler Material (Below 501 J s TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewerv`s I 4 available within 200 feet.) ,Installation will serve: Residence_ Commercial_ Other Number of living units: Numberof bedrooms Character of soil to a depth of 3 feet:-4 - - - --- '�' Water-table-depth---- SEPTIC TANK ❑ TypelMfg i Capacity Na Compartments PKG. TREATMENT PLT. ❑ ( Mdthod of Disposal Distance to nearest: Well Foundation Property dine I . LEACHING LINE ❑ No. & Length of lines Total length/size j/ FILTER BED ❑ Distance to.nearest: Well Foundation Property!Line r SEEPAGE PITS I I Depth Size Number E SUMPS Ll Distance to nearest: Well Foundation Propertne i DISPOSAL PONDS ❑ 'P ] 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: "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." 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." The applicaritnust call for all re iced inspections. Complete drawing on r verse side. f e Signed e: _ Date' j ' 1 FOR DEPARTMENT USE ONLY i Application Accepted by ��L _ _ Date_10 r O O 1 Area 1 I Pit or Grout Inspection by � Date Final inspection by �. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3699-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMn"NO, +.EH 1314 IR[°V. /x 57 J �'?_a y W—UZ7 EH tt-2e J Q