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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE'TON AVE., STOCKTON, CA Telephone (209) 46E-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. 1662 for well/pump and the Files and Regulations of the San Joaquin Local Health District. T Q, SF Job Address �� City ! `Q _5F `__Zot Size_ PM Owner's N �_�_ � Address d-✓V�- Phone Contractoraris �Address 7j�t/ ��, License No � —Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,ft OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES CISPOSAL FLO. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 117 Industrial ❑Open Bottom ❑ Manteca Dia.of Well Excavation Dia-of Well Casing Iff Domestic/Private T❑Gravel Pack ❑Tracy Type of Casing_ Specifications ('1 Pubic 17 Other Il Delta Depth of Grout Seal Type of Grout-- - I I Irrigation Approx. Depth I I EasternSu ace Sedl Installed by Re t Work Done Type ype of Pump �� H.P. _ State Work Done Well Destruction ❑ Well Diameter Sea!mg Material(top 501 ! Depth ,'Ater Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 FILPAIR/ADDITION I I DESTRUCTION I I (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 soil to a depth of 3 feet: Water table depth { SEPTIC TANK Ll Type/Mfg _ _ _ Capacity No. Compartments K PKG. TREATMENT PLT.El Method of Disposal Dis13nce to nearest: Well._ Foundation__ Property Line LEACHING LINE D No.8 Length of Imes _ .__ Total length/size- FILTER BED Ll Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number _ SUMPS I I Distance to nearest: Wall . Foundation Property Line _ DISPOSAL PONDS t I 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 Dilstrir-t. 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 subleet co workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following."I certify that in the performance of tho work for which this permit is issued,I shall employ perrans subject to workman' compensa- tion laws of California." The applicant t call for all required i ctions ompl drawing on re/v/yee side. g Signed X a _ Title:_ ri Dsts ` FOR DEPARTMENT USE ONLY / L �J Application Accepted by — _—_ __ Data �`f / r/ c� Arse � L Pit or Grout Inspection by _ O�tu Final Inspection by Z /� t- Date r Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 6237104 El Tracy B35-&!I85 Applicant- Return all copies to: Environmental Health Per m%t/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH r:;��RECE INFO IVED BY DATE PERMIT NO. IH 13,24 IRFV, fM 1�26 ��