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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,T 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 �l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'n (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 r 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 r Local Health District. I �/ d' CE v Lot Size PM Job Address 7 t:' < _ I Owner's Name - C/-'^)C. Address - Phone: Phone " Contractor G Address 15 License No. TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LAVE r FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I a El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ` Dia. of Well Casing ❑ Domestic/Private i ❑ Graval, ack-:. 7 Tracy- -- _ 'Type of Casing { Specifications i ❑ Public ❑ Other T ❑ Delta 1 Depth of Grout Seal k Type of Grout ❑ Irrigation ; --Approx. Depth 111Eastern Surface Seal Installed by Repair Work Done EJType of Pump H.P. State Work Done 1 ? Well Destruction El ( Well Diameter Sealing Material flop 501 t j Depth Filler Material (Below 50') E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ '(No septic system permitted if public sewer is available within 200 feet.I j y � —Installation will_serve:-.�Residence•�Commercial_ -Other Number of living units( ( ' I Water table depth r j Character of soil to a depth lof 3 feet: �; 1 a i I SEPTIC TANK i0 type/Mfg t' ' �~`� Capacity ' No. CompaRirients CLI ' { PKG. TREATMENT PLT.,.❑ F 7- '.. Method of Dispbsai _ - ' i � Property Line i ':Distance to nearest: .Well `� Foundation � � + LEACHING LINE �❑ No. & Length of lines Total length/size / FILTER BEd ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS it❑ Depth.. Size Number SUMPS ❑ .Distance to nearest: Well Foundation Property Line F� r DISPOSAL PONDS ?❑ �7,„ hereby certify that I have prepare^this application and that the.inrork•will'be done in accordance'�with San Joaquin county ordinances, state laws, and I' rules and regulations of the San Joaum 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,asyfo become subject,io,workman's compensation laws of California.”Contractor's hiring or sub-contracting signature certifies the following: '`I certify-het•'ih the performance of the work for which this permit is issued,I shall employ persons subject to workman 's compensa- tion laws of California." }: a *� 1. € �. The"applicant must call for all quir " i9.spect+ons�Complete drawing on reverse side. Date: Signed ' {{ x. FOR'DEPARtMENT USE ONLY y s / Date .97` v Area Application Accepted by t L ! '.� Fi"al Inspection by, Date/ Pit or Grout inspection by ,. ; Additional Comments: ❑ Stk 466-6781 C Lodi' 369-3621 ❑ Manteca -7104 t ❑;Tracy 835-6385 j t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box.2009, Stk., CA 95201 r• .� - -- - -- CK# RECEIVED BY - DATE _ PERMIT N0. ��" x. .. FEE AiVIOUNT DUE AMOUNT REMIFrED ' INFO L CASH + H1324IREV.�/861 O�s E �S fS1Ar EH 14-26 L �.rp-LA.V/J .. -