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�: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT i 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 s 13, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED``' I (Complete in Triplicate) t 'a application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harem described. This app' 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. City .. Lot Size PM Job Address A m Address sq Phone Owner's Name � " 6-�. a-i �'"` �j// 2 C1 Phone 2 t Contractor � itt,C) Address�l�'7�y License 1V - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR gr" OTHER ❑ DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE .- - - 'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ED Industrial ❑ Open Bottom EJ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ElGravel Pack ElTracy Type of Casing EI Public ❑ Other D Delta Depth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth Eastern urtace Seal installed by Q.rtr* a Repair Work Done J1 Type of Pump H p State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ -DESTRUCTION ❑ (Noavasepti7Ysip lable system ted if public sewer is Installation will serve: Residence_ Commercial— Other t Number of living units: Number of bedrdoms WaCharacter of soil to a depth of 3 feet: r -- Capacity r � n No.SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ ` Meal1,� �Foundation Property Distance to nearestWell LEACHING INE ❑ No. & Length of lines Total length/size �r Ito 1 Foundation Property Line FILTER HED El Distance to nearest,; Well t SEEPAGE PITS " El[3 j f 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 District. Home owner or licensed agent's signature certifies the'following7� l ce1tify that in the performance of the work for which this permit is issued, ! shall not any person in such manner as to become subjec employ t to workman's compensa tion laws of California."Contractor's hiring or sub contracting signature employ 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- certifie tion laws of California." 1 - - ` The applicant must call fo II required inspections.(Complete drawing on reverse ide. 3 Title: Date: Signed FOR DEPARTMENT USE ONLY / Date f �Area Application Accepted by t + D e Final Inspection by �- ✓Pit or Grout Inspection by Additional Comments: A- V r. ❑ 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 !. K RECEIVED BY DATE,- PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITT C H } INFO 't +EH 13-24(REV..1is51 Cj ti_ j© EH 14-26 ...�- - - .. �- ,.........Lv