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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA ! Telephone (209) 466-6781 �,/} fJ8$—f 70—Zff 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 in described. Ns he S anication Joaquin is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for p p and the Rules and Local Health District. C191,11 Lot Size PM Job Address Address [�(/t // �i Phone Owner's Name y t �/ Contractor �[� ddress aG? License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION CI PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �3� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL --' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `r L] Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavationyy��,,�� Dia. of Well Casin.� j Type f/! S $7Domestic/Private rave! Pack ❑ Tracy T Yp of Casing— Specifications ' � — _ I /(-1 Public n Other Cl Delta Depth of Grout Seal Type of Grout } I I irrigation 7—&.Approx Depth I I Eastern Surface Seal Installed by S Repair Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RFPAIR/ADDITION I i DESTRUCTION € I (No septic lable cyst m relined if public sewer is avaInstallation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well\ Foundation Property Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to pearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number 14-1 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict. 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." h The applicant s II re ctions. Complete drawing on r v r, side, Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Data Area 4 Pit or Grout Inspection by i Date — Final Inspection by fs7�t Date l Additional Comments: i ❑ 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 } FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. INFO E + EM 13-24 IREV.1/9 51 EH 1428