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' APPLICATION FOR PERMIT ► SAN JOAQUIN LOCAL HEALTH DISTRICT } " 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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. Job Address 6-7,5-1 C—- A-(` r' .;� City Lot Size PM Owner's Name VO" ' W ' ` ' IjAddress 5-1,57 C ` &4A-"R Phone Contractor 5a F Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ❑ —SYSTEM REPAIR ❑ OTHER ❑ T' � 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ,, FI Public n Other F1 Delta Depth of Grout Seal '.Type of GroutV�j1 I I Irrigation __-Approx. Depth I I Eastern Surface Seal installed by I Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑', Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is i --available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms A Character of soil to a depth of 3 feet: = Water table depth `'~ SEPTIC TANK LJType/Mfg a a R No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to neD rnit 141? E-E)q�di*'th ut Property Line y [� i J (, yg completed or LEACHING LINE L-1 No. & Length yo.,� (nes ��.�� Total length/size \\ FILTER BED ❑ Distance to nelafv&n�fNIR111�L' h��sion Property Line SEEPAGE PITS I I Depth Size Number 3 SUMPS L� Distance to nearest: Well f=oundation Property Line DISPOSAL PONDS ❑ i 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 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X / _ Title: v""fy Date: a FOR DEPARTMENT USE ONLY Application Accepted by ._ _ Date Area Pit or Grout Inspection h Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-W85 , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT//REMITTED •CASH RECEIVED BY s. DATEPERMIT'No. ♦.EH 1 -241REV.1/451 [y� 9 47`12'y EH 1428