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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .a I 1601 E. HAZELTON AVE., STOCKTON Telephone (209) 466-6781 CA PERMIT EXPIRES tYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heioby made to the San.Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is I made in compliance with San Joaquin County Ordinance No. Local Health District. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin r Job Address ! {� I Cityo ;�"�rtf Lot Size Owner's Name`-�7`i rt t PM 410 r Address L7� G Phone 46�`/6.0 7 Contractor .,Te/ ( Address TYPE OF WELL/PUMP: NEW WELL ❑ License No. Phone + WELL REPLACEMENT ❑ DESTRUCTION ~ PUMP INSTALLATION El ❑ DISTANCE TO NEAREST: SEPTIC TANKSYSTEM REPAIR L] OTHER ❑ —�� SEWER LINES .... . DISPOSAL FLO. FOUNDATION AGRICULTURE WELL PROP- LINE INTENDED USE TYPE OF WOTHER WELL PITS/SUMPS ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom —�� 11 Domestic/Private ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy T Dia, of Well Casing MPublic ❑ Other Ype of Casing ❑ DettaDepth of Grout Seal Specifications I 1 Irrigation �.-Approx.'IDepth [ I Eastern Type of Grout C7 5uriace Seal Installed by Repair Work Done Type of Pump H.P- Well Destruction ❑ Well Diameter State Work Done_ I Sealing Material (top 50') Depth ! Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTAkLATION I 1 REPAIR/ADDITION ! I DESTIII CTIONI ¢ {No septic system permitted if public sewer is Other Installation will serve: Residence Commercial avada6le within 200 feet.) + � Number of living units: Number of bedrooms (- Character of soil to a depth of 3 feet:• ! r Y SEPTIC TANK ❑ Type/Mfg` Water table depth PKG. TREATMENT PLT. ❑ Capacity— No. Compartments z Method of Disposal Distance tonearest: Well-,Foundation Property.Line LEACHING LINEi ❑ Na. & Length of lines + FILTER BED ❑ Distance to nTz earest: Well t Total length/sie i Foundation Property Line f l y, SEEPAGE PITS 11 Depth Size dumber SUMPS ❑ Distance to-nearest: Well '^r DISPOSAL PONDS ❑ Foundation_. _�' Propevy Line 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 DI Home owner or licensed agent's signature Certifies the following: "I certify that in the performance of the employ any person in such manner as to become work for which this permit is issued, I shall not subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is i tion laws of California." ssued, I shall employ persons subject to workman's compensa- ure The applicant ust call for ail required inspections. Complete drawing on reverse side. Signed X Title: 'j�ifJ —� Date: FOR DEPARTMENT USE ONLY Application Accepted byV,_," ` . i Date \\-1A - &Z Area Pit or Grout Inspection by Date_.,��` Final Inspection by Additional Comments: Date �7 1 ❑ Stk 466-6781 O Lodi 369-3621 i LJ Manteca a23-71040 Tracy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Avg., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE � AMOUNT REMITTED CK C H RECEIVED By EM PER11-71-NO, EH 14 +.EH 14-2s-241REV.ri++sl Q f/ �j E