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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) Joaquin Local Health District for a permit to construct and/or install the work herein d Application is hereby made to the San escribed. This application is ith Sall Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin made in compliance w Local Health District. City ^"r Lot Size PM Job Address 71 I yu Phone Owner's Name ��t �� ddress i �58 License NoPhone Contractor ~ Address .� _ WELL REPLACEMENT ❑ DESTRUCTION El TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM-REPAIR-❑-, OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL-FLD. PROD. LINE . DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER,WELL f ITSISU,MPS INTENDED USE TYPE OF WELL—PROBLEM.AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca' Dia. of,Well Excavation Dia. of Well Casing Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy" Type of Grout Other El Delta Depth of Grout Seal yp M Public - 1.1 Irrigation APProx. Depth i I Eastern Surface Seal Installed by W s H,P- State Work Done_ Repair Work Done ❑ Type of Pump Well Destruction El Well Diameter 5ealing Material (top 50'1 Depth 3 Filler Material (Below 50') system TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I (No seperwithin 200 feet.) it public sewer is Installation wilt serve: Residence— Commercial—' Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Y r Capacity to en No. Compartments SEPTIC TANK [!r—Type/Mfg, %JLX ethod of Disposal PKG. TREATMENT PLT.❑ ,�¢0.9SL 1 I Distance to nearest: 1/VeII Foundation C� Propert Line { �tal length'/` size LEACHING UNE EPS No.,8:Length of lin s oundation Property Line f FILTER BED ❑ Distance to nearest: Well .Orl i SEEPAGE PITS I I Depth Sixe ~ , f Number SUMPS 0 f 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, anis rules and regulations of the San Joaquin Local Health Dltrict. ,y I Home owner or licensed agent's signature certifies the following:,'.'I cerfifyrhamat 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"';Contractors 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 comp e.nsa- tion laws of California." , The apRi4eantmust call for all required inspections. Complete drawing overse side. (71 Signed r Title: Date: f _ T USE ONLY Date Area yQ) `-' 'F - Application Accepted by .__ ... , ate Pit or Grout Inspection by I T ~ Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621-- ❑ Manteca.r 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 5FEEEUN AMOUNT REMITTED CKRECEIVED BY DATE PERMIT�NO. CASH EH 14-215 _ 3763. 1'..1; +.EH t3-24[REN.v/e sl L