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- I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' (Complete in Triplicate) Application is hereby made to the Sari 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. „ t? Y * City c Lot Size , PM Job Address ` '- / yf ..F � T O.IV Phone �4' ^, a7 Owner's NameirA11"I��r� 1 A(0 Address N � 4s! Contractor A �✓ rY ddress AD Ik X OA License No.��Phone 3J I TYPE OF WELL/PUMP:"' '" N£W'WELL❑"�°7" 'WELjREP ENT'E3 " '�DESTRUCTION Ely I PUMPINSTALLATiONr � ��Y�iCntPAIR,❑ OTHER 13 PK TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1Industrial ElOpen Bottom 171Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private LlGravel Pack ElTracy Type of Casing Specifications ± Public , ❑ Other E-1DeltaDepth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth r❑l Easter rFace Seal Installed by Repair Work Done Type of Pump_J(�[d76• - State:W:ork Done 5 i Well Destruction Well Diameter Sealing Material Stop 50'1 Depth Filler Material iBelow 501 �,} TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION 13 DESTRUCTION E) (No sepeiwi h in permfeet'Med if public sewer is iN Installation will serve:. Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth'o#3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line - LEACHING LINE �" ❑"Nfa & Length f lines Total length/size FILTER BED t. ❑ Distance to nearest: Well Foundation Property Line r Number SEEPAGE PITS ❑ :Depth Size 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 Districts Home owner or licensed agent's signature certifies ttfie 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." The applicant must call for all required'inspections`Complete drawingon revers/e side. Signed Title: 49 A ee Date: FOR DEPA`RTM£NT USE ONLY i Application Accepted by�° ^' ^Date 4�Area Pit or Grout Inspection by Date i` Final Inspection by Date c � Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca X823-7104 �A'.❑ tracyl 835-6365 Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT"NO. INFO r i + EH 13-24IREV.-1/851 S �/ �is _ j-7 11 EH 14-28