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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON-AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.),2-$ S ..�, // ` , r/�- A-- PM x� 'A City Lot Size Joh AddressLML--�.1110111111� ^ __ - - Address .2 �� - Phone " 6 Z Owner's Name /— �. N License No. 3 o 7.'/ Phone Contractor's Name TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION F-1 7-77 PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private rave ❑ Gravel Pack Tracy...- Type of.Casing I � P T of Grout L1 Public EI Other ; 1:3 Delta Depth of Grout Seal . Type ❑ Irrigation . --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done } r � Well Destruction ❑ Well Diameter I Sealing Material (top 501 Depth Filler Material (Below 501 3 TYPE OF'SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ availabllelwi h within if public sewer is Installation will serve: Residence 1- Commercial_ Other ;} k lnsta ,L� i Number of living units: -J— Number o edrooms _ Water table depth 9,0 Character of soil to a depth of 3 feet:' No. Compartments f SEPTIC TANK ❑ Type/Mfg j Capacity -..4,.Method of Disposal PKG. TREATMENT PLT. ❑ 5Property Line k Distance to nearest: Well Foundation s� s r • LEACHING LINE^- - G�No..& Length of lines -Total length/size I r°- t + . Property Line FILTER BED ❑ ""Distance to nearest, Well low'_ Foundation s y — "� Number S * - EEPAGE PITS �DBpth Size + % �^ I— t Foundation `Property Line SUMPS ❑ 'Distance to nearest: Well 1 t DISPOSAL PONDS ❑ hereby certify that l have prepared this application and that the work will be done in accordance with Sant Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. : 1 for which this permit Home owner or licensed agent's signature certifies the following: "I certify that in the,performance of the work 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 pers6ns subject to workman's compensa- tion laws of California."< The applicant must call for all equi d inspections. Complete drawing on reverse side. t Title: /L� x , Date: Signed �•-- e FO DEPARTMENT USE ONLY r S Date Area Application Accepted by 4 1►- �� Final inspection by -� Date l /p'glor Grout Inspection by ��- —� Date spB 6 � — ��/ -- j Additional Comments: ' ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-8386 mit/Services 1801 E. Hazelton Ave., P.O. Box 2009. Stk CA 95201 1 Applicant- Return all copies to: Environmental Health Per El CK RECEIVED BY DATE PERMIT"NO. AMOUNT DUE AMOUNT REMITTED CASH _ v -8s $s-1` 11 l + EH 13-24(REV.10183) EH 1428