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i I ' APPLICATION FOR PERMIT ` , SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZELTON AVE., STOCKTON, CA �� Telephone (209) X166-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED No I' (Complete in Triplicate) 1 ., Application is hereby made to the San Joaquin Local Health District for a permit to construct an dlor install the work herein described. Th1s a plication is .549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No Local Health District. p+ t O �/ ' ( /4'�J� City 57 "" Lot Size PM Job ddress J/}p. Own. Name ft/c& (�V/7L�I� Addre s� �Ln �sJ �• . : .411`5 "`-�•Phon Contractor Address License No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION LlSYSTEM 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 ❑ Manteca Dia. of Well Excavation w Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _ -_. Type of Casin 9 Specifications f� Other . f Cl Del{a Depth of Grout Seal Type of Grout f`l Public a, I I irrigation _ —.-Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material IBelow50'! ; TYPE OF SEPTIC WORK: NEW INSTALLATION {'I REPAIR/ADDITION (.I DESTRUCTIO 1Nolabetic syste tt m perfe it ed if public sewer is Installation will serve: Residence 11 Commercial Other i Number of living units: Number of bedrooms Character of soil to a'depth of 3 feet: Water table depth SEPTIC TANK L) Type/Mtge Capacity No. Compartments PKG. TREATMENT PLT. ❑ r 1. _-- ��: -1, -.-- _ 11 - - - --Method-of Disposal Distance to nearest: Well Foundation Property.Line _ LEACHING LINE ❑ No. & Lelrigth of lines Tota! lengthlsize FILTER BED ❑ Distance!to nearest: Well Foundation Property L'ine''- SEEPAGE PITS 11 Depth Size Number + SUMPS L] Distance to nearest: Well Foundation Property Line-` DISPOSAL PONDS ❑ It I hereby certify that I have prepared this application and that the work will be donein-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 n 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." i The applicant m call for ail equire inspections. Complete drawing on reverse side. ned X Title: Pate: 19 FY �- �PA�RT�M�ENTONLY Application Accepted by 1 Date Area Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: '77-3 Q - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH 13.241REV.1/n51 EH 14.26 .a