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APPLICATION FOR PERMIT SAN JOAQUIN�LOCAL.HEALTH DISTRICT 1601 E. .HAZELTON AVE., STOCKTON, CA `Telephone (209) 466-6781' PERMIT EXPIRES,I.;YEAR FROM DATE ISSUED c4✓� r4 --� "JLx ;? :`°'t 3�3 9lti D 'i.of ".-3-..;;`31 ,_.�,y).,,t;r„(Qprnplete in Triplicate) : s1', YTZ,• `x, 9+.;i. 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 coinpliance'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 Job Address City�� Lot Size . PM Owner's iVame %( /� �/r� 7� »Iddress _ Phone YTContractor's Name r EL ` TJ ��`�2 License No. Phone r TYPE OF WELL/PUMP: 1 NEIN WELL ❑ V 'WELL REPLACEMENT 0 DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ,t Q Manteca r Dia. of Well Excavation Dia. of Well Casing Q f ❑ Domestic/Private L1Gravel Pack 11Tracy i /Type of Casing Specifications ❑ Public s ❑ Other ❑ Delta ` Depth of Grout Seal Type of Grout ❑ Irrigation z -_LApprox..Depth ❑ Eastern Surface Seal Installed by .Repair Work Done , ❑ t Type of Pump H.P. State Work Done x. Well Destruction ❑ Well Diameter' Sealing Material {top 541 Depth. Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ available within 240 feet.) Installation will serve: L Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:, } Water table depth :SEPTIC TANK' T❑ Type/Mfg Capacity No. Compartments `.PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to"nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' , -7 - u❑ -Distance to nearest: 'Well Foundation Property'Line SEEPAGE PITS ❑ Depth I -Size' Number f -SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS_ ❑ 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:"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. :The appl- ant ust,call fora ' u' d i ctions. Complete drawing on reverse side. Signed Title: .��' Date: �— : . FOR DEPARTMENT USE ONLY ' Application Accepted by� Date/ ` Area Pit or Grout Inspection by i Date Final Inspection by Date l TA itional Comments: Y f 7� Stk 466-6781- ❑ Lodi -369-3621, D Manteca .823-7104 .: ❑ Tracy83�r6385 l Applicant,- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009„Stk., CA 95201 FEE; AMOUNT DUE ”` AMOUNT REMITTED C RECEIVED BY DATE" PERMIT'NO. E ' ,INFO t SH . +EH 13.24(REV.101831 .� 1 _ to t 7 O 1__ [P—T(1 $l•1~! V3 'j EH 14-28 r c i