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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA r _ RECEIVED Telephone 12091 466-6781 o- ;- 0 C T 0 q 190 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN jOAQUIN i`i"Di_IINTY {Complete in Triplicate) ��pp PiipUp�ByLIC H1.AL'TH SErr_�/IC F's Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo�'15�FL�9%9WA f0Q4HiDV(6I6N 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 i Local Health District. r Job Address 7 � LSC �(s[ r City Lot Size PM Owner's Nam �li .� i Address '111 Y � LJ c� Phone /'T --5 3 r9 /� J Contractor �&;y C'��r I Address 7 ¢ L} L License No.�G S:M20-_,__Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G4- 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 El Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing !1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications }� 1`1 Public M Other ' ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _._Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done { Type Of Pump H.P../_. Zo `._ State Work Done �• Well Destruction ❑ Well bg Material Ip 50} biometer Sealing to , Depth Filler Material (Below 50')'- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is f available within 200 feet.) 1 Installation will serve: Residence_ Commercial_ Other P. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i "t- _ °§` '• Water table depth I SEPTIC TANK ❑ Type/Mfg; Capacity a No. Compartments PKGyTREATMENT PLT. ❑ - s. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line I , t' SEEPAGE PITS i I Depth I Size Number SUMPS L_l Distance to nearest: Well _-Foundation. - - Properly-L-ine�= u 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:Loca! Health Di%trict. . 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 subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies 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- tion laws of California." I The applicant must call for all wrequired inspections. Complete drawing on reverse side. Signed X �- a ' Title: `[x .Date: go I FOR DEPARTMENT USE ONLY Application Accepted by `W Date ea Pit Or Grout Inspection by ' Date Final Inspection Date/ Additional Comments: i u ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, .,StkCA 95201 f � i FEE AMOUNT DUE ' AM INFO OUNT REMITTED G RECEIVED BY DATE PERMIT-NO. f + 13-241 REV.tiH51 EH 14-29 i 5 �� 0h_/q t