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APPLICATION FOR PERMIT ! SARI JOAQU1N LOCAL HEALTH DISTRICT /� F 1601 E. HAZEL T ON AVE., STOCKTON, CA ; Telephone 12091 466-6781 SAN JOAQUI6,, !! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED kL�J-d �j� 10 �- ! CA t (Complete in Triplicate) .. 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. 1862for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ti r. y . {.: ,� 11b: I t x T✓5 t -, �� City Lot Size - PM Job Address _ - ,- Address Phone Owner's Name y Contractor's Name -L -ILicense No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.2" OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` t DISPOSAL FLD. PROP. LINE. FOUNDATION AGRICULTURE WELL� OTHER WELL ?ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ca Dia. of Well Excavation ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Casing Specifications � PoDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing [I Public ❑ OtHer El Delta Depth of Grout Seal Type of Grout © Irrigation --L-Approx. Depth ❑ Eastern urface Sea stalled by Repair Work Done ❑ Type of Pumpl.I _ N.P. State Work Done 6 1 Well Destruction ❑ Well Diameter. Sealing Material Stop 501 Depth Filler Material IBelow-50'1 6 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ .(Nailabltic thin system permitted if public sewer is Ln a y' 1 y Installation will serve: Residence__ Commercial_ Other Number of living units: Numbe of bedrooms 0 Character of soil to a depth of 3 feet. "s Water table depth_ -4 3�, No. Compartments +t . SEPTIC TANK 11 (Type/Mfg i � � Capacity Method of Disposal ?KG. TREATMENT PLT. ❑ : t ,,,� . _�.' -44" -�+ ►�� •> � Distance to nearest:`- Well"`"""-Foundation Property Line } fi LEACHING LINE ❑ No. & Length of lines _ Total length)Property r e Line Foundation P oP rty FILTER BED ❑ Distance to nearest: Well l SEEPAGE PITS ❑ Depth 1 Size Number rty SUMPS ❑ Foundation PropeLina Distance to nearest: Welt ,;. r 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 following: "1 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,00mpensation laws of California."Contractors hiring or sub-contracting signature ich this permit is issued,I shall certifies the following:"I certify that in the performance of the work for wh shallemploy persons subject to workman's compensa- tion laws of California." _ r The applicant must call f all required inspections. Coinplete drawing on r OrseSiitde- Title: Signed Date: F FOR DEPARTMENT USE ONLY Date 31�� Area `3 I Application Accepted by ZS�3 l Pit or Grout Inspection by Date Final Inspection by kDate I Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 C: Manteca 8237104- ❑ Tracy 835 - , 6385 ' Applicant- Return all copies to: Envirorimental 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 13.24 MM 14193]- '�"'`�. �^J 1 k's EH.14-26 i