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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICt 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1 Job Address rinap -��j a��^ City Lot Size PM Owner's N ��/�� ddress � Phone -2xS Contractor -"""- Address ��CQ (r P_0*10t License No!� G O Phone�9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i 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 TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing ' rte, f El Domes tic,LPAV.4[te��GraveS Pate\ ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout j ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth — -----Filler-Material[ABelow 50'1# TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION C7 (No,septic.system permiVed if public sewer is available within 200 feet.I { r " Installation will serve: Residence Comr�lercial:.� Other i � Number of living units: Number of- edr omt � , (� Character of soil toad pth of 3 feet: T dVatel`13b1e depth _ No. Com artmdnts SEPTIC TANK IL—Typp/.Mfg._ .. ,T`,ap�qty p kL PKG. TREATMENT PLT. ❑ _ Method of Disposal 4 Vl .,' r Distance to nearest: Well ou6dation ,- Property L+ne LEACHING LINE No. & Length of lines Total length/size 3 (� FILTER BED 1` "'"❑-"Dist9'hce fo neatest:-Aell undi§tioro�� Property Line4� r SEEPAGE PITS ;;� Depth _e� Size .�+ r ' Number 1 A SUMPS ❑ Distance to nearest: Well �F&ndation-%-i , Property Line�O DISPOSAL PONDS ❑ 1 I hereby certify that I have prepared this application anJ that the work will be done i llaccordance'with San Joaquin county ordinances, state(aws, 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 subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." The app- ant t cal d inspecti ns.-Complete drawing on reverse side. Signed X Date: /Z c FOR DEPARTMENT USE ONLY Application Accepted by Date A Area a ( Pit or Grout Inspection by Datq Final Inspection by 0)�14Date f Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca N823-7104 ❑ Tracy 83546385 Applicant- Return 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 ZPERMIT'NO. INFO CASH + EH 13-24 4REV.1 i 8 5S ly71 E '+(.I G>l EH 1429 Q.� r L� 7 t