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f n n a _ �. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (249) 466-6781 PERMIT EXPIRES T 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€nsiall the work herein described.This application is made in compliance with Sari Joaquin County Ordinance No.549 lot sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin r Local Health District. SS S . ,� 9,S-aSla � Job Address ,� »�-+ City P Lot Size PM Owner's Name e�*z�p - -- Address � r�'P, _ Phone ~6 •6 I Contractor Address License No.=�61 Phone r TYPE OF WELt/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF-WE-CL'�40BLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ IndustrialDpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l D Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing_ �T►r C_ Specifications --".d I`I Public n Other 171 Delta Depth of Grout Seal 81,6`8s Type of Grout��/ I I Irrigation _App rox. Depth i l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _ tel State Work Done AZmj6l+Jtu r Well Destruction ❑ Well Diameter „Sealing Material(top 501 rs 414, Depth Filler Material(Below 501 96-15" TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIRlADDITION I I DESTRUCTION I I (No septic syslem permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial T,.-, Other Number of living units: Number of bedrooms V1 Character of soil to a depth of 3 feet: _ __ Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG.TREATMENT PLT.❑ Method of Disposal e Distance to nearest: Well Foundation Property Line r _LEACHING LINE ❑ No. 8 Length of lines. Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 I hereby certify that 1 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 Datr€ct. 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 pirsons subject to workman's compensa- tion laws of California." r The applicant must call for all re wired Inspections. Complete drawing on reverse side. 4 r Signed Title: Date: ARTMENT USE ONLY Application Accepted by (�,n-� Date �' Area �— l , Pit o Grou Inspection bv- `t Y` '�-'�J Date ' el incl Inspection by Date Additional Comments: f vi et7 fkoel ❑ Stk 468.8781 ❑ Lodi 369.3021 ❑ Manteca 823-7104 ❑Tracy 835-5385 Applicant-Astum all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. sox 2009, Stk., CA 95201 CK 0 _MOUNT AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. !M] 3 ..Hr 13.24IREY-If 45) t EH 1418 t