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`- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT !� J 1601 E. HAZEJ N AVE., STOCKTON, CA OCT 2 9 19 f Telephone (209) 466-67811. �4 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED- .1OAQIJIIV LC)C AL (Complete in Triplicate/ HEALTH DISTRIIC, 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 incompliance with San Joaquin Count Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District._. aL"rF1 . ' , p / - City Lot Size P I Joh Address ' _ - - �✓k -- -. _Phone . ._�_ Address Owner's Name �,__. .� �-�--_��.. ;,�: •-r-- -- Contractor's Name License No. T a Phone TYPE C WELL PUM NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 9 SYSTEM REPAIR ❑ OTHER C] DISTANCE TO NEAREST: SEPTIC TANK SEWER_LINES DISPOSAL FLD. PROP. LINE 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 _ Type of Casing Specifications 9 50 Domestic/Private ❑ Gravel Pack` ❑ Tracy g Type of Grout ❑ Public El Other l 11 Delta Depth of Grout Seal YP 6 ❑ Irrigation --Approx.-Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noavaseptilable cyst m rmiitted if public sewer is 9� Installation will serve:-Residence" Commarcial_ Other- - Number of living units: Number of bedrooms tar table depth 1 Water p S Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK LlType/Mfg Method of Disposal PKG. TREATMENT PLT. El ° rProperty Line Distance to nearest: Well Foundation e LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED o 13Distance to nearest:, --Well Foundation Property Line jy SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS . ❑ f 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:"1•carrify 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 applicant must cal for all required inspections. Complete drawing on reverse side..11 4PSigned Title: - "" _ ,tea Date: OR DEPARTMENT USE ONLY 1 - /" 7r ' Date Area Application Accepted by Pit or Grout Inspection by { Date Final Inspection by Additional Comments: I El Stk 466-Ml EJ Lodi 369-3621 ❑ Mantsca 823-7104 ❑ TracY �`-- ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED C INFO, ASH +EH 1324 IREV.10183? EH 14-28 - i