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a INV 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) + on Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Hs app cats uis of made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations Local Health District. }S( City Lot Size PM Job Address T Lo �yt� Address Phone Owner's Name rrn "3"Address :3 C L fico h�icense No. Contractor = — - TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , T.- PUMP-INSTAL-LATION-C-J - SYSTEM-REPAIR"❑ OTHER`❑ 1 DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;,_Dia.,of-Well.Casing__."--• - ; ❑ Industrial ❑ Open Bottom _❑ Manteca Dia. of_Well,Excavation, Specifications k -" Type of Casing r p �❑ Domestic/Private ❑ Gravel ❑ Tracy g Type of Grout ❑ Public ❑ Other - C] Delta Depth of Grout Seal € ❑ Irrigation ---Approx..Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter ' " '"Sealing lNaferial Itop 501 Filler Material (Below 50') t Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/ADDITIONTRUCTION available septic system tem emitted if public sewer is mercial ther r mm Installation will serve: Residence O — - �" Number of living units'~ Number of bed roo s ��'� Water table depth Character of soil to a depth of 3 feet: f�4 SEPTIC TANK ❑ Type/Mfg Capacity -- No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ �'�r-� Distance to nearest: Well� Foundatiori Prpperty Line I i i ' Total length/size LEACHING LINE I �Length of lines '�' ` l" Foundation�"Property Line FILTER BED ❑p Distance to ilearest:� Well '" k Y � 14" t r I } r SEEPAGE PITS " ❑ Depth,;;' Size Number " _ — :Propel Line SUMPS d Distance to nearest:�Fi Well FoundationY DISPOSAL PONDS ❑T I� 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, a rules and regulations of the San Joaquin Local Health District. j 1 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 ploy any person in such manner as to become subject to workman's compensation laws of California." ploy cersonshiring sub ect to wosub-contracting compensa- i certi the following:"I fy that in the performance of the work for which this permit is isFued,I shall employ p 1 tion laws California.' ^ " 1 i... k .$ applican t all'for all r ui mp a dra - g on fgverse si i t 4- -k +� ` F Date: a--)— Signed f r FOR DEP RTMENT USE ONLY Date ZV A a DCF Application Accepted Y. 1 't (J Pit or Grout Inspection by ate Final Inspection by ` Additional Comments: ; 11 [I Stk 466-6781 '❑ Lodi 369-3621 ❑ Manteca- 823-7104 ❑ Tracy 835 B385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED 8Y DATE PERMA101. FEE 1 AMOUNT DUE" AMOUNT REMITTED CASH INFO+ EN 13-24 IREV.f/n 5) 66 -�� ..? EH 14-28 s