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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL) 7HEALTH DISTRICT ,k %.-„, 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES 1'YEA'RIFROM-DATE 1S$UED° (Complete_ 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin 4 Local Health District, AIYr -w -4 M Job Address ” a� D City Lot Size PM 1Y . Owner's Name Address Phone i 1 Contractor Address License No. Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑" s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP..LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r❑ Domestic/Private ❑.h ravel Pack ❑ Tracy Type of Casing 'Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' I ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑r Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r 1 Installation will,,seryp: Residence Commercial_ Other Number of living units: Number of bedrooms- Character.of.soil.to a.deptF-of 3.feet:- Water table depth - " SEPTIC TANK ❑ Type/Mfg � ,� Capacity .4o-a!0 4 No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal ii Distance to nearest: Well MAtG Foundation Property Line BLEACHING LINE No. & Length of lines Notal length/size F 'J. • FILTER BED ❑ ! Distance to nearest: Well Foundation" Property Line 1 _ � ;SEEPAGE PITS ❑ Depth f2 Size mber` j ('[SUMPS � � Distance to nearest:_ Well FoundationProperty Line `.DISPOSAL PONDS ❑ l a ',1 hereby certify thaf l have pi6pared this application and that the work'will be done,in aaccord5 a with San..'Joaquin county ordinances,state laws, and Trf rules and regulations of the San Joaquin Local Health District. "" -�" `J f' 4" l Homeowner or licehsed agent's signature certifies the,following: "I certify that in the performaMce of the work for'which this permit is issued, I shall not ,employ any person in suchmanner as to become subject to workman's-compensation laws of California'.,"Cohtractor's hiring or sub-contracting signature eicertifies the following:"I certify that in the performance of the work for which"this permit is issued,I shall empjoy persons subject to workman's compensa- tion laws of California." IThe,applicant must all fo all re 'red inspections. Complete drawing on reverse side. E Signed X ;-_2; VIP,. Title: I ? l Date: } FOR DEPARTMENT USE"ONLY r Or Application Accepf+�d'tiy I _-� "��=` Date ` Area r N Pit or Grout Inspection by "I�I Date J J Final;lnspection by Date L1! .Additional Comments: I! 1!S :. .+ I❑ Stk 46&6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 4Tracy 6:35-6385 'u Applicant- Reirirn all copies!to: Environmental Health Permit/Services 1601 E. Hazelton Ave: :P:O."Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY _ �,-DATE-�.r --PERMIT'NO.=• INFO "--__ ___ — - --- _CAS H• -+ + EH-13-24 dREV-l a 51------ _` -.Q Q... .,� •,--... ._ _ �. ..•=1��1�/, ..�._ ��. (� S•- "-' [� EH 14-26 TT