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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH -DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I � , (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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,I Job Address d LO �'* T City Am Lot Size PM t Owner's Name A-57A I—u/tr♦T Address yf0 C� [� !1 �i7� Phoneme Contractor /� /' • �1 Address RVr License No.coc$ $hone TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM ARA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca 6a. o{Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications �. f ., d 1-1PublicV1 OtF er ❑ Delta fDep h,,of Grout Seal Type of Grout I i Irrigation #Approx. Depth I Eastern f Surface Seal Installed by _ E Repair Work Done ❑ Type,of Pump H.P State Work Done Well Destruction ❑ Well;Diameter Sealing Material Itop 50'1 ► i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRYADDITION I 1 DESTRUCTION 1Na septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms r y Character of soil to a depth of,3-feet: Water table depth SEPTIC TANK ❑, Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispose! Distance to nearest: Well Foundation Property Line } s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation Property Line SEEPAGE PITS I I Doth s Size Number SUMPS ❑ Distariee to nearest: Well .Foundation Property Line DISPOSAL PONDS ❑ v I hereby certify that I have pr pared this application and that the work will tie•done in"accordance with San Joaquin county ordinances state laws, and rules and regulations of the San�Joaquin Local Health District,.i ,f y Home owner or licensed agent's.'signature certifiers 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§ubject to workman's.compens'6ti6n 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 pefmif is issued, I.shall employ persons subject to workman's compensa- tion laws of California." i f The applicant must call for all required inspections. Complete drawk"g on reverse side. -s. Signed X, ' Title: Date: e_1d_112C �! t`1�4C)Fi DE=PARTMENT USE ON_LX`` � t ta , ` Application Accepted by �__�� -K" pate L Area fin J 1 Pit or Grout Inspection by Date Final Insp tion by Oat/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi .369-3621 13 Manteca 823-7104 ❑ frecy 835-6385 —Applicant i Return all copies,.to:.dEnvironmental_Health.P.erkt/.Services,1601-.E. Hazelton.Ave.,.R.O..B x-2009,.Stk.,-CA-95201.-FEE ~ T INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT-NO. i EH �. + EH 13-24[REV. i H 51 "7 ,� _1� `7 _'7-]y� 14-26 G-(�C3 ✓f CA d _. -