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. A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT it 1601 E. HAZEL T ON AVE., STOCKTON, CA �� I Telephone (209) 466-6781 # PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) j*f`� W_A, application is Application�s hereby de to t e San Joaquin Locale Health District for a permit to construct and/or install the work herein described. This made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulationsof the San Joaquin Local Health District. pOH _p �� PS C2a �d'zG�� C" r �v' 5' Y?? 7y Job Address d City S fy Llk!�!V Lot Size PM -11 CA C A LN S Address S 9 U U / Phone Owner's Name 6--5?- Contractor — Phonal/�3r1 Contractor�_ �+ �t�wr�Address 5 to"R License Ko, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM 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 y 17ia. of Well Casing 1V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing A Specifications Public X0ther [] Delta Depth of Grout Seal Type of Grout C.vYr1�i ��-- ` 1 1 Irrigation I4;1741_�._Approx. Depth 1 1 Eastern Surface Seale Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction • ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I 1 DESTRUCTION l I availablelwithin 200 feetitpermled if public sewer is installation will serve: Residence— Commercial— Other __U Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth { SEPTIC TANK LJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line h i �1 LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth Size Number SUMPS ❑' 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 Di1trict. 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 of 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 tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. � � � 7apted Signed � Title: �' Date: FOR DEPARTMENT USE ONLY Application y Date Area Pit or Grout Inspection by Date O �7 Final Inspection by DateIP Additional Comments: [ ❑ 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 CASH RECEIVED BY DATE PERMIT NO. INFO � + EH 13-241REV.1/Hsl 35 EH 14-26 -