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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DI :r . -. ._ . STRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA -Telephone•42091 466-Mi PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' t4 -» (Complete In Triplicate} .. Q r: .,:' .�� -,r-dr'.' 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. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. g �> Job Address/ / ` f/. Cityy r' Lot Size `f x";fir PM j Owner's•Name Address �>`_- �'�/ r Phone�� v - +��i�CiC.�i a' License NJ 6 Contractor Address �3z} q! ��373Phan TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION'❑ PUMP INSTALLATION ❑ ,ySYSTEM REPAIR P--' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEF-LINES DISPOSAL FLD. I PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ell 0 C1 Manteca Dia. of Well Excavation Dia. of Well Casing R`b-omestic/Private ❑f Gravel Pack'd ❑ Tracy Type of Casing Specifications ❑ Public ❑t Other , • ` ❑ Delta Depth of Grout Seal- 1 Type of Grout i S _�'lrrigation E�pproz, D th 11'Eastern - Surface Seal Installed by i Repair Work Done- 0' T4e'of Pump 'H.P._ S State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Fiiier Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system'permitted if public sewer is 1 I available within 200 feet.) Installation will serve: Residence— Commercial f Other Number of living units:• Number of bedroom-Is Character of soil,to a depth of 3 feet: 6 f Water tabledepth SEPTIC TANK Ll Type/Mf9 4 . Capacity No. Compartments ` r PKG.,TREATMENT PLT. .. l Method of Disposal r Distance to,nearest: ,Well Foundation_ y' Property Line J LEACHING LINE ❑ No. & Length of lines Total length/size " '' ''• : r' FILTER BED ❑. Distance to"nearest: Well Foundation 3 Property Line l } SEEPAGE PITS ❑ ' Depth I. Size Number SUMPS ❑ Distance to nearest: Well Foundation ) Property Line DISPOSAL PONDS Q I hereby certify that•l-have-prepared-this-application-and-that-the work•viiilf#ie dane--inaccordaihce with-San Joaquin county ordinances, state laws,'and rules and regulations of the San Joaquin:Local Health.District. it 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's 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." � .� s The applicant ust II for-al uired inspections. Complete drawing on reverse side ` t 2 I ' Signed X - 1 - !/'Title: FOR DEPARTMENT USE ONLY `k Application Accepted by ' Date Area Q ✓r 4 // Pit or Grout Inspection by + Date Final Inspection by Datell Additional Comments:---- 0 omments:❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009;Stk., CA 95201 } INFO AMOUNT DUE ' AMOUNT REMITTED c CASH.. RECEIVED BY.., DATE x PERMiT'NO. FEE +EH 1324(REV.I/s 5) "�... d_, .+ EH 1426 . S © o . - /I!oir41. �b-ham i