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APPLICATION FOR PERMIT 0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA HAI. (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _. Ii(Complete in Triplicate) ' i Q' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he he on, escncn This p kation 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. ti iE�l r 7s/ s �S Job Address G Lot Size .- PM I _ 1 Owner's Name 04�,Y� Phone (� ` _ P_ _ y ��Contractor dress License No. V Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE }}} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM!AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialO--Open-Bottom--- L3 Manteca T—Dia:-of� -Well Excavation- -°s-- – ------ pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy I� Type of Casing Specifications ( ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by € { Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 \ Depth Filler Material (Below50') 7 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP 41 DD ON ❑� RUCT N c jseptic system permitted if public sewer is .. y E.. avai le within 200 feet.l Installation will serve: Residence _— Commercial Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of,Disposal r _.—1 Distance to near ;t v... –wellf �FoundRtion – - Pr'openry Line F LEACHING LINE ❑ No. & Length of lines ! Total length/size Q FILTER BED ❑ Distance to nearest: Well,111 Foundation Property Line SEEPAGE PITS ❑ Depth ' Size Number r SUMPS ❑ Distance to nearest:`It' ,Well t, Foundation Property Line ! DISPOSAU PONDS ❑ I hereby certify that I have prepared this application and thatlthe work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. 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 employ any person in such mariner as to become subject to workman's compensation laws of'Califomis." C6ritractor's hiring'or sub-contra6ting,signature certifies the following;$1 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 applica ust call gforI required ' spectiohs. Complete.drawing on reverse side. p f t. r / Signed �� Title: a-GCJ'7�'7 �t/� ` Date: r .w FF PARTMENT USE ONLY Application Accepted by � '�"�• _ �`P Date ;Area Pit or Grout Inspection by f Date' Final Inspection by Date �C► Additional Comments: Yy ❑ Stk 466-6781 ❑ Lodi 366-3621 ❑ Manteca if j 823-7104 ❑ Tracy 835-63$5 s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 952 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE 74PERM1T'N0Q,.J7, r'EINFO _- _ ,__ _ __ .CASH Ev.t/857 ►' }