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d APPLICATIONFOR PERMIT ` y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.;.STOCKTON, CA Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (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.5.49 for sewage or No. 1862-for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -a- _ _ .fir � (�� Job Address `- _. �5` - - �� City�drr►`��'� t` Lot Size PM Owner's Name Address �� Phone -� 73 Contractor QAddress icense No. Phone TYPE OF LL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYP&&� WELL ?)PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom e❑•Manieca„„" Dia. of Well Excavation Dia. of Well Casing= ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I El Public ❑ Other ❑ Delta — Depth of Grout Seal Type of Grout ❑ Irrigation ;-Approx. Depth ❑ Eastern Surface.Seal Jnstalled by Repair Work Done ❑ Type of Pump j H.P. State Work Done Well Destruction ❑ Well Diameter Sealing"Material"..{top.501 Depth Filler Material_iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is a available within 200 feet./ Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg Capacity No. Compartments `PKG. TREATMENT PLT. ❑ Method of Disposal I - I Distance to nearest: Well Foundation Property Line P , I LEACHING LINE ❑ No. & Length of lines Total length/size l k .FILTER BED ❑ Distance to nearest: Well Foundation- .- ProperI Line's " V SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation—'"1 Property Line I DISPOSAL PONDS ❑ 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, and 'A rules and regulations of the San Joaquin local Health District. f - ,49 } 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 manner as to become subject to workman's compensation laws of California."Contr'actor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work fol which this permit is issued, I steall employ persons subject to workman's compensa- tion laws of California." I; - The applicant must call for all requir inspect'onS. Complete drawing on reverse side. Signed 4V 7VTitle: �Gr=/n.. / Date: �- 7 FOR DEPARTMENT USE-ONLY Application Accepted by Daily Area "Pit or Grout Inspectio ' e--'' Final Inspection `Additional Comments: t oi ❑ 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 99M FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO + EH 13-24 iREV.t i H 5] �� .�� - �.�8 '3—Zl�•� ""' EH 14-28 V