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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Addressacq n 'el TI) City,4�O' C-Itot Size— PM Owner's Name;;� RO-d A01 r-- Address :5C, Phone �r 'F & � License No.32)69!�!D__PhoneVK2—Za.;L Contractor A-r—it t 171 . ,&C_-Address j2!J). TYPE OF WELL/PUMP: NEW WELL EJ WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR X' OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FUD._ PROP. LINE FOUNDATION AGRICULTURE WELL — OTHER WELL— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial d O� n�aott� 6 Manteca Die. of Well Excavation Die. of Well Casing b6 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casin Specifications El Public 0 Other D Delta Depth of Grout Sea] Type of Grout El Irrigation --Approx. Depth D Eastern Seal Installed 09 H.P.. SX! State Work Done4;44 , ce Pi� Repair Work Done )4 Type of Pump 5.O� Well Destruction El Well Diameter — Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION El DESTRUCTION 13 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units:— Number of bedrooms Character of wil to a depth of 3 few: Water table depth SEPTIC TANK 0 Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. 11 Method of Disposal Distance to marest: Well— Foundation— Property Line LEACHING LINE El No. & Length of lines Total length/ i FILTER BED El Distance to nearest: Well— Foundation— Property Lim SEEPAGE PITS El Depth —Size — Number SUMPS Ll Distance to nearest: Well— Foundation— Property Line DISPOSAL PONDS E 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."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 applic::�ust call for all r uired in ctions. Complete drawing operse side. 9 Signed Title. Or 49 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout lnspect,6�1_�=_ Data— Final Inspection by Z:�]� Additional Comments: El Stlk 466-6781 El Lodi 369-3621 EI Mantaoa 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Servims 16DI E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK III RECEIVED By DATE INFO 6 CASH 1� 1P1A11_+ EH 1�24(REEV EH 1�26