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APPLICATION FOR PERMIT I' SAN JOAQUIN LOCAL HEALTH DISTRICT G 1601 E. HAZE.. i ON AVE., STOCKTON, CA Telephone (209) 466-67$1 1� ----ti PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) d 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. li i� / i Job Address.- ` ` __- City Lot Size / w Owner's Name Contractor TYPE OF 1 DISTANCE TO NEAREST INTENDED USE L Industrial LJ Domestic/ Private "I Public I I Irrigation Repair Work Done 0 Well Destruction C ess NEW WELL O PUMP INSTALLATION ❑ SEPTIC TANK FOUNDATION TYPE OF WELL ❑ Open Bottom C Gravel Pack G. Other # —..Approx. Depth Phone 4!" p �- WELL REPLACEMENT CJ DESTRUCTION 71 U SYSTEM REPAIR ❑ OTHER ❑ �I SEWER LINES DISPOSAL FLD.___�_ PROP. LINE . AGRICULTURE WELL -OTHER WELL PITS/SUMPS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ii ❑ Manteca _ Dia. of Well Excavation _ Dia. of Well', Casing Ll Tracy Type of CasingSpecifications i1 11 Delta Depth of Grout Seal Type of Grout I Eastern Surface Seal Installed by i H.P. State Work Done _ .4. " Type of Pump � _ _. ` Well Diameter t Sealing -Material .itop 50'i Depth ....___4 _� Filler Material IBelo�ai'0'} n ]YPE OF SEPTIC WORK: NEW INSTALLATION{ I 1 REPAIR/ADDITION IV DESTRUCTION I I (No septic, system permitted if public sewer is J available within 200 feet.) ' Installation will serve: Residence Z Commercial _ _Pther �I Number of living units: A— Number of bedrooms —!2 Cf lafar, •t Of o Sot to a ep o Ly a or a e pt `i/ SEPTIC TANK L Type/Mfg. DATE Capacity No. Compartments PKG. TREATMENT PLT. LI .41. " �j Method of Disposal 77 Distance to nearest: Well r it Foundation'Property Line47 LEACHING LINE f7, No- & Length of lines t/ -Total length /size. — FILTER BED n Distance to nearest: Weil _ Foundation Property Line I. SEEPAGE PITS I I Depth f Size l —�__. Number �% h SUMPS L Distance to nearest. Well Foundation Property Line -i DISPOSAL PONDS O 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 Diltrict. II 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." Contractors 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." 1 The applicant SnustSall for all raq it d inspections. Co ete drawing on. revers—Z""137 - �I 7�Signed Title:- Date: _,..._ FOR DEPARTMENT USE ONLY �I � A � s •: „a r II Application Accepted by -G��tL /// �9{z,� Dare �� Area Pit or Grout Inspection by Date Final Inspection by Date Lf -_3Additional Comments: � 6 L �.. c � f/ �r 41 EIStk 466-6781 ❑ 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385yyss c. 4 t I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 JD .,EH 13-24 tREV. t Msl EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17' NO. / —; /I