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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCTON, CA Telephone (209),466-678.I PERMIT EXPIRES 1:YEAR FROM DATE`ISSUED,' r--- {Complete iri 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 arid Regulations of the San Joaquin Local Health District. y Job Address f �' i/Y /�f�'/� O p R'6/;fi /� PM r I nr Ci Ii 40-4 Tt fLvl', tee.) Ml:-J aaY caner Name Addre _ Phone r r ej �rac��n � i/V /Ares .Z© /.ZCO�t License Na.AA 17 Z 6 Phone .Z O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATIONSY TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES `MT DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ 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 Seall Type of Grout ❑ Irrigation ---Approx. Dept ❑ Eastern S dace Seal Installed by Repair Work pone ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') 6 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .. available within 200 feet.) d Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 4 . Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg"?% _ Capacity .No. Compartments 1 ff PKG. TREATMENT PLT, 1-1 *Method of Disposal I Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ No. & Length of lines Total length/size .� FILTER BED ❑ Distance to nearest: Well Foundation } Property Line : f ! SEEPAGE PITS ❑ DepthSize f Number a SUMPS ❑ Distance to nearest: Weil t FoundationProperty Line DISPOSAL PONDS ❑ f I hereby certify that 1 have prepared this application and that the work"will-be donein accordarice 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 oerti ies 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 signatureI 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 compe tion taws of California." i. t The applicant f all r ired inspections. Complete drawing on reverse e. Signed Ti#le:""` - - - Date: �4 S_ FOR DEP TMENT USE ONLY ; t Application Accepted by Area Pit or Grout Inspection by Date Final;nspection by Date Additional Comments: 119'x.. U IyL .k 1 ❑ Stk 466-6781 Lodi 369-3621 ❑ Man 823-7004 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.Hizetton Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. a INFO CASH ' + EH1 3-24(REV.r/85) ,- EH 14-25 S ca a ct�