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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELLTI ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXOIRES 1-YEAR FROM DATE ISSUED l (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 AddreslSl // Q City I— LotSizes i Owner's Nam.7_0& "' Address Phone '. /�� Contractor Addles License No TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ice^ SYSTEM REPAIR O +� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1AZ_GY_CSEWEFt LINES DISPOSAL FLD. PROP. LINE .. _ FOUNDATION `.'AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing omestic/Private ❑ Gravel Pack ❑Tracy Type of Casing specifications f� f'1 Public ❑ Ogler n Delta Depth of Grout Seal -;'0 Type t I I lrriluation R _Approx. Dept I I astern Surface Seal Installed by� _.. �j� - Repair Work Done ❑ Type or Pump I H.P" Z State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 : i. 'i Depth Fifler Material 18elow,50') �tl A TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I.1 DESTRUCTION I 1 (No septic system permitted if public sewer is UY available within 200 feet./ LP Installation will serve: Residence Commercial_ Other N `- + i Number of living units: Number of bedrooms f i Character of soil to a depth of 3 feat: r ! Water table depth SEPTIC.TANK 4 'y ❑ •Type/Mfg r r Capacity No. Compartments y 1. ,� . PKG..TREATMENT PLT,❑•_f— 3F € Method of Disposal Distance to nearest: Well [ Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size w FILTER SED ❑ Distance to nearest: Well Foundation _ Property Line a SEEPAGE PITS 11 Depth Size Number r SUMPS Ll 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 6- 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 Califomla."Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued,!shall employ persons subject to workman's compensa- tion laws of California." .do, The applicant must call for all required inspections. omplete drawing on reverse side. • Signed K _ Title: eP�u► 'r- •_ _ ._ Date: t FOR DEPARTMENT USE ONLY f ~ r J Application Accepted by _ 10(0 ��rr Date Area Pit or Grout inspection by c Data `7'�L�� Final Inspection by ��' Date s• � Additional Comments:; ❑ Stk 466-6781 . ❑ Lbdi 369.3621 (3 Manteca 823.7108 ❑Tracy 835-6385 t Applicant- Retum.ail copies to: Environmental Health Parmlt/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk., CA 45201 S INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED SY �y DATE PERMIT*NO. r +EH 1324 IREV.118 5l �• �/l EH 14.26ecs