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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 ' a (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 Ryles and Regulations of the San Joaquin Local Health District. - S .. .... L� r � Job Address 11670'� �' '�� j Ci i� I Lot Size - PM Owner's Name Y � ir Address _ y� �+� �t5 - _ _- Phone i J l Contractor/� ��C�]`/�S JlJ"' Address 0'�tj M ISI N License No.�7/�/.�T__>'llone TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION <SYSTEM REPAIR-El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER NES ' B ' 1 i"+ -ADISPOSAL FLD. PROP. LINE FOUNDATION-_=_- AGRICULTURE-WELL -- OTHER`WELL"" '"'""` 4PITS/-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 71 Tracy Type of Casing Specifications ❑ Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -!--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done +tel Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ available within 200 feet./ Installation will serve: Residence_ Commercial_ Other r Number of living units: ' Number of bedrooms r Character of soil to a depth of 3 feet: :Water table depth SEPTIC TANK ❑ Type/Mfg ^! F~ µ ^Capacity - V No. Compartments+ PKG. TREATMENT PLT. ❑ `r �* �" t 5�� 'w`"+ IMethod of Disposal i Distance to nearest: Well Foundation _ r � 4-roperty Line r" jt� LEACHING LINE ❑ e.No. & Length of lines Total length/size FILTER BED' ❑ Distance to nearest: Well Foundation Property Line 1•1 a SEEPAGE PITS �T "*O% DepthSize Number SUMPS ' ❑ , Distance to nearest: f .A Well - y Foundatiori � Property Line ` • -DISPOSAL PONDS - I hereby certify that I have prepared this application and that the w'ork'will be'done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin.Local,Health District. k.+. . N ♦ i i l.a ) i Home owner-or licensed agent's signature-certifies the following: "I certify that"in fhe 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 bf 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 compen_sa tion laws of California." ` + The applicant m st call for al quired i io omplete drawing on rever side. `f Signed �" — Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b Date Area Area `/'2 7 e Date 5 / Pit or Grout Inspecti by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant -Return all copiesito: Environmental Health Permit/Services 1601 E.'Hazelton Ave:, PiO. Boz 2009" Stk.,'CA•95201_ . t •3s"''� .1� kis'a:-,R` i' FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"NO. INFO + EH 1324[REV.f/85) �J EH 1428