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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;n compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District- Job Address 4�6 L/ City 5�G4L ot Size PM Owner's Name ✓� 6� q ///tvV I �"'��"` 4dress ~ �.�� o Phone r y� X9 7'0 o e�/6-d g!- Z Contractor � 'v'L Address ✓ License No, b Ph TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 0 Industrial - ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing V1 ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications f1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �w I I Irrigatfom• / Approx. Depth I I Eastern Surface Seal Installed by _ a.�, Repair Work Done O Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing MeteriaH1op-W')-- Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION 1r REPAIR/ DDITION I I DESTRUCTION I I (No septic system permitted if public sewer is I ✓ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 4 Were;table depth SEPTIC TANK ❑ Type/Mfg OV4 capacity—�-f -- No. Compartments PKG. TREATMENT PLT'. ❑ - - 'ry2f (!- '' Method of Disal, n ... Distance to nearest: Well (� Found ion—L/�'l—/�L-- Property Line�r' LEACHING LINE No. & Length of lines �;wTgtal length/size FILTER BED Distance to nearest: Well Foundation leProperty Line SEEPAGE PITS re Depth Size Number SUMPS ❑ Distance to nearest: Well I Oroundation / PropertyLane 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 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 shag not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." Theapplicanu c I mall required inspections. Complete drawing on reverse side. r v Sig Title: 01. C on,;� ,_tv _ Dat /FOR ARTMENT USE ONLY Application Accepted by DataArea Pit or Grout Inspection by �+r / Date/ /�J Final`Inspecxion by / Date / Additional Comments: "�� dAl�i ��T T Oy�YB�"''( r713J 0 Stk 466-6781 0 Lodi 369-3621 O.Manta 1123-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2109, Stk., CA 95207 • d u.;Aa ++� e%.lcrtlw_ 1 INFO AMOUNT DUE �� AMOUNT REMITTED ''fK RECEIVED BY DATE PERMI7'NNO.