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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 4 6- Telephone 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. ,A/� dAl Al— Job Address /— �L �� V IC� City Lot Size PM Owner's NameC ��f �. Address z t U t 14 5 4 _ _�sgh Phone Etc*/L"i -5e L A C9 Address too, Z / Contractor g ��K ��'7 lair• t:�� License No.�Z� � � Phone��'��'�f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 El industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public rl Other ❑ Delta Depth of Grout Seat Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Seating Material Imp 501 Depth Filler Material ff ii0ow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) J 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 SEPTIC TANK ❑ TypelMfg �y Iy`iY j _ Capac4y_ -' 2" No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ^ No. & Length of lines Licif Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Z _Size 74 Number SUMPS Ll Distance to nearest: Well y 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, slate 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, 1 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 applican / call 7 all req ctions. Complete drawing on reverse side. Signed �_y��. L — Title: _ ZJ b,'2" Date: /ezw FOR DEPARTMENT USE ONLY Application Accepted by v tit Data v � , Area t _ Pit or Grout inspection y Date Final Inspection by Date Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy a35-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Bort 2009, Stk., CA 95201 FEE INFO AMOUNT OUE AMOUNT REMITTED cK H RECEIVED BY DATE: /y J��P1,E(yR+M11 NO. . EH 1IA-29 3-2 EH 6 MFVL i�nSi n� ,� JS 1'l2 -b 0ej �y lift