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a. APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA N� tlr� -�'- Telephone 12091 466-6781 - e PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Ih Job Address ` SAM:RU City Lot Size PM L- Address �� 7v ar' U 9, � Phone Owners Name F_RN - S �` Address S M License No. Phone G ntractor® + TYPE OF WELL/PUMP: I` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL D :-LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications [-I Public CI 0 h {1 Delta Depth of Grout Seal Type of Grout I I Irrigation _L.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done 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 I1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is II vailable 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 ,i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments fPKG. TREATMENT PLT. ❑ Method of Disposal 'i Distance to nearest: Well Foundation Property Line 4 h _ LEACHING LINE ❑ No. & Length of lines Total length/size 9 Ca FILTER BED ❑ 'iDistance to nearest:' Well Foundation Property Line SEEPAGE PITS I I ((Depth Size Number SUMPS 0 `Distance to nearest: Well Foundation Property Line DISPOSAL�,PONDS ❑ II 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 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 manner as to become subject 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." .The applicant ust call for all required inspections. Complete drawing on revers8-side. Si ned X Title: tE: Date. g I l EPARTMENT USE ONLY Application Accepted by Date- _ - Area Pit or Grout Inspection by !� ate +Final Inspection by Date lZy�V� Additional Comments: Vf at's ❑ 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 2008, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTEDC S RECEIVED BY DATE PERMIT N0. INFO a EH 13-24 MEV.t/n 51 �r V d EH 14-26 �3�j jD w V