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f i APPLICATION FOR PERMIT 1 HEALTH DIST SAN JOAQUIN LOCAL RICT � a"' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' ' (COm fete in P rn Tripficatel `-`` ;" ":'"f T� cap y Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ��t..t .r �.`j r L.. �{� 1 f made in compliance with San Joaquin Courtr;:R T Local Health District, r ty Ordinance No. 549 for sewage or No. 4862 for well/pump and the Rules and Regulations of the San Joaquin work herein described. This application n Job Address � cam_.-- f � City Lot Size Owner's Name PM Address ��a,..��. lists, Contract Phonef t� --�—•�— t�Address t� �.-- TYPE OF WELL/PUMP: License No, i gni NEW WELL ❑ WELL REPLACEMENT ❑ Phone PUMP INSTALLATION � DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ SEWER LINES OTHER ❑ FOUNDATION AGRICULTURE WELL DISPOSAL FLD._ PROP. LINE INTENDED USE TYPE OF WELL OTHER WELL,�� PITS/SUMPS El industrial PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ~'— ~ ❑ Domestic/Private ❑ Manteca Dia, of Well Excavation ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ,Public n Other Type of Casing I I Irrigation Ll Delta Depth of Grout Seal Specifications p i --Approx. Depth I I Eastern TYpe of Grout Repair Work Done Surface Seal Installed by —. ❑ Type of Pump H. 1 Well Destruction ❑ Well t]iameter State Work Done Sealin M.terial�(topr5n,,I Depth FilleM TYPE OF SEPTIC WORK: .7 :'l; '' QQ NEW INSTALLATION I DITI0N [.1 DESTRUCTION 17 t.No septic systrmit installation will serve: Residencem Permitted i e "available withif public sewer is n 200 frmit Number of living units: Commercial Other Number of bedrooms Character'of soil to a depth of 3.feet: SEPTIC TANK Q Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ " Capacity-- No, Compartments Distance to nearest: WellMethod of Disposal d ---� Foundation_ Propdrty.Line LEACHING LINE4 ❑ No. & length of lines � - FILTER BED ❑ Distance to nearest: WellTotal Iength/size Foundation�,�_ Property Line SEEPAGE PITS f I Depth SUMPSSize Number ❑ Distance to nearest: Well PONDS ❑ Foundation_ Property Line 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 Di§trict, 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 employ p performance of the work for which this permit is issued,I shall em tion laws of California." y persons subject to workman's compensa- tion applicant m !f r all required ins ctions. Complete drawing on r rse side. Sig Title: i Date: a R DEPAMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by/6' Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 36973621 ❑ Manteca. 823-7104 ❑ Trac Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton A3 e63P.O. Box 2009, Stk., CA 95201 FEE OUNT DUE CK INFO AMOUNT REMIT-TED E RCEIVED 9Y CASH DATE PERMIT N0. •-EH 13.24(REV.11m sl I EH 14-2e -