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APPLICATION-FOR PERMIT �I SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE,;;STOCKTON, CA Telephone-(209) 466-6781 PERMIT EXPIRES ! YEAR FROM DATE ISSUED ... 4 . (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 J 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 A r a City Lot Size PM " Owner's Name i- ., As 41. °Address ii Phone Contractor L Iddress ��0 l�►`t!/�Q� L�c��f �P ��j �+. ,License No. Phone3'" TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT ❑ Ny DESTRUCTION ❑ PUMP INSTALLATION C1SYSTEM REPAIR 'OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD�--` PROP. LI `� `� _ NE FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS > INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ . Specifications ❑ Public ❑ Other ❑'Delta ! Depth of Grout Seal '- Type of Grout ❑ Irrigation �pprox. Depth ❑ Eastern Sarfacekeal Installed by Repair Work Done El Type of Pump J H.P. u . State Work Done_ J� 6, Well Destruction ❑ Well Diameter Sealing Material [ta I , p �50'1 n f '1 Depth �1 Filler Material {gelo -5 TYPE OF SEPTIC WORK: NEW INSTALLATION,Ll REPAIR/ADDITION DESTRUCTION [No septic system permitted'f public sewer is 11" available w_ithin 200 feet.( Installation will serve: Residence Commercial they " - l Number of living units: �M Number of betlrooms Character of soil to a depth of 3 feet: / �r Water table de th SEPTIC TANK ?__T�ype/Mfg 4 {' Capacity No. Compartments r PKG. TREATMENT PLT. EJ J { Methog of Disposal Distance to nearest:. Well poundatlori Property Line U<J i i? LEACHING LINE ^�o. & Len th of li es ,rte ` 9 Total length/size Ak FILTER BED F-1 to neare, sP-well `�auntlatron --Property Line��_ "��" SEEPAGE PITS �pth Size,, Numbers-' SUMPS ❑ Distance to nearest: Well Foundation_�'Propert�,Line DISPOSAL PONDS El I hereby certify that 1' avt�i p spared 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: "1 certify li 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 ap i t must c� required i ctions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date AJ l F'iYor Grout Inspection by F Date Final Inspection by Date. VAdditional Comments: I� ❑ Stk 466-6781 ❑ Lodi�� 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE. AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. 4 + EH 1 -241REV.1i951 EH t4 7o IIOo 1"rr tF-7 -28 i