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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) IS-7-3Y d9 Z 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. r 7_7" �.� .. Job Address •h ` }, - City Lot Size PM y l , Owner's Name eS't- 1-Address C �� 5_� � Phone r �/ � 1 i Contractor r^ Mfg-Address cJ'T40 Ae4l4ak� 4LRcense€No Phone 3 TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEO USES TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ia Industrial j " "❑ men Bottom"" ❑ Manteca Dia:.-of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C f'l Public n Other F- Delta Depth of Grout Seal ; Type of Grout _.,�] 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 r ❑ Well Diameter Sealing Material (top 50'1 ' ; Depth Filler Material.(Below"50'I 4 .;-TYPE OF,SEPTIC WORK: NEW•INSTALLATION I 1 REPAIR/ADDITION I_'W'DESTRUCTION 111No septic system permitted if public sewer is 7 1 available within 200 feet.1 ^� Installation will serve: Residence_ Commercial_ Other i (Number of living units: Number of bedrooms # Character of soil to a depth of 3 feet: Water Cable depth 'SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D _ Method of Disposal Distance to nearest: Well-� Foundation Property Line r LEACHING LINE ❑-X-No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Propetty Line SEEPAGE PITS l I. Depth Size Number ? SUMPS Ll 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;foli6Wng ."I certify thatiri fhe performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in tha_performance,of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic"ustfor all requi inspections."Complete drawing on re arse side. 7_13 y f�j Signed X Title_:_ _ __ _ :,_.— Date: / _!3 FOR-DEPARTMENT-USE ONLY - - �l+�•--_-p,V{ Application Accepted byALM , Date 9-1�„� `O 'f Area 40 3 1 Pit or Grout Inspection by �'� Date Final Inspection by � date Additional Comments: 1�22 7 '�� 0 Stk 466-6781 ❑ Lodi 369-4621 " ❑ 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 j y t FEE 13INFO AMOUNT DUE AMOUNT REMITTED REC ED BY DATE PERMIT"NO. ,,.�r C H ' + EH 21(REV.1/n sY _ C C �� EH 11-2tt VW`�