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r , n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (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 install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wallipump and the Rules and Regulations of the San Joaquin r Local Health District. 471-,?20 0.,Ov.a, Job Address .t •- C — City Lot Size 4& PM Owner's Name nshew Address _ Cd��!•P - - Phone w6 70-16 I Contractor Address &/5 & —License no. 96-/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ 4 SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ",SEINER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL PITSISUMPS INTENDED USE TYPE OF WEMIL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �y I El Industrial Open Bottom ❑ Manteca Dia. of Well Excavation 47 Dia. of Well Casing 1 LJ Domestic/Private ❑ Gravel Pack E3 Tracy Type of CAsina— ;-T4-A.L Specifications lD9e I1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout�'. __. I I Irrigation —Approx. Depth I I Eastern Surface Seai Installed by _ Repair Work Done ❑ Type of Pump �l State Work Dane A ac& r Well Destruction ❑ Well Diameter _ „Sealing Material {top 501 r s Calf Depth Filler Material IBelow 50'1 -f f TYPE OF SEPTIC WORK: NEW INSTALLAT16N 1.1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 fact.} Installation will serve: Residence, Commercial_ Other Number of living units: Number of bedrooms V% Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ! - �❑ No. &Length of lines, Total longih/size r FILTER BED ❑ Distance to nearest: Well Fouiidation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DI§trlct. Home owner or licensed agent's signature oertifies the following:"I certify that In the performance of the work for which this permit is issued, I shall not F employ any person in such manner as to becoma subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature 1 certifies the following:"I certify that in the performance of the work for which this permlt Is issued,I shall employ pirsons subject to wofkrnan's compensa- tion laws of California." r The applicant must callfor all re ulred inspection Complete drawing on reverse side. SignedTitle: -- _ Date: Air ARTMENT USE ONLY Application Accepted by Date Area —Z � l Pit o Gro inspection by, Date —lr -'�inal Inspection by Date Additional Comments: eG.v+'r v Wa- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑Tracy a35-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEEOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO G--O t EN t..te 9