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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ryrtE PERMIT EXPIRES'" YEAR FROM,DATE ISSUED_ {Complete in Triplicate) .. = r �:,1 . %ii t)b-o ' I . 1 ., �� .•�.._ , . 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. KJ]f! yX/1�Ll37y4n4 ,y +i Lot Size ` PMCityJobAddress _TOwner'sName "Address ( `�/� � Phone Contractor's Name _ �t License No. 3oS 7/` Phone,364� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j s I ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1Industrial ❑-Open Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing [D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 7-1OtherClDelta Depth of Grout Seal Type of Grout i❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Instalied by Repair Work Done 11Type of Pump{ H.P. State Work Done -Well Destruction ❑ Well Diameter Sealing Material {top 501 I Depth i. Filler Material (862w Z,) TYPE OF SEPTIC WORK: NEW INSTALLATION 14EPAIR/ADDITION DESTRUCTION ID (No septic system permitted if public sewer is t _ r 1 available within 200 feet.) Installation will serve:_ Residence_ Commercial Other Number of living units:_ °Number of bedr oms ' -Character of soil to a depth of 3 feet: V ` Water table depth moi , SEPTIC TANK ❑ Type/Mfg Capacity-ix-010 No. Compartments I PKG. TREATMENT PLT: ❑ +/ y Method of Disposal � `Distance to nearest!-,- Well Foundation Property Line + f " LEACHING LINE �NO. & Length of lines Tota! length/size� - I FILTER BED `❑ ,Distance to nearest: Well Q . "Foundation s Property Line. A a iSEEPAGE PITS # t❑ ,Depth - -Size _ IS ' Numfiei r SUMPS 9?-,-Distance to nearest ' 4 Weil b1 .-.Foundation V Property Line 56 0 T ," a i DISPOSAL PONDS ❑ ' 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 andHome of the San Joaquin Local Health District. `" ,:. 41 - '- - t 'Home owner or licensed agent's signature certifies the following: '9 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 Yaws of California."Contrac[o�s hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- _ �'_ '-tion-jaws-of California.,^'- _ _y. -- 't } .. - � ,� • _ The applicant must c for II required inspections. Complete drawing on reverse side. .g" t. �1 F" 4 _.,- �} �,. ,pate: I Signed " Title:_ T r- T # ► FOR DEPARTMENT USE,ONLY -10-16 r ,,Application Accepted by, Date - Area Date Final Inspection by Date a Pit or Grout Inspection by .,Additional Comments: ' 0 Stk -466-6781' ':- ❑ Lodi--369-3621 ❑ Manteca 823-7104 --❑:Tracy 635-638.5 F Applicant- Return aH copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r CK RECEIVED SY DATE PERMIT''NO. T EFEF ' AMOUNT'DUE AMOUNT REMITTED CASH O' ' rt EK 13.24 IREV.10!891 - EH 14-28