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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE COPY (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. Job Address - 1107 Ci { City . Lot Size /� pM Owner's Name e ' C�-Jrl.4� Address Phone Contractor's Name % 'f,� [l J � License No. 2 J_ `,3� 7 ! TYPE OF WELL/PUMP. Phone' !� f NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ `A PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ )v DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES W DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! If Bottom L7 Manteca Dia. of Wel! Excavation ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ! ❑ Tracy Type of Casing ❑ Public Specifications ❑ Other El Delta. Depth of Grout Seal ❑ Irrigation TYPE of Grout ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work bone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material fBelow 501) 1" TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewet is _ Installation will serve: ResidenceCommercial available within 200 feet.) _ Other_ Number of living units:. Number of bedrooms - Character of soil to a depth.of 3 feet: '1Water table depth / SEPTIC TANK L�Type/Mfg /.' PKG. TREATMENT-PLT. O CapacitY—f3�_ No. Compartments , i Method of Disposal Distance to nearest: Well /40Foundation_;�Q _ Property Line LEACHING LINE 9i"'No. & Length of lines 2_ --- ' Total length/size FILTER BED ❑ Distance to nearest: Well ' Foundation ° ��`� �.. -f— - Property Line - SEEPAGE PITS ❑ Depth Size Number SUMPS ,❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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."Contractors 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 applican call for all re ' d inspections. Complete drawing on reverse side, Signed Title: Date FOR DEP TMENT USE ONLY y Application Accepted by Date ��p . Ac - Date Area Pit or Grout Inspection by . Date . Final Inspection by / Additional Comments: p, ❑ 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 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED CK INFO t ( CASH RECEIVED BY DATE PERMIT'NO. + EH 13,24(REV.1e/831 0� �4��5 Eli 74-4-26 i;