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J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 0091 4668781 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 irtatM the work hashdMptJed.This apps 86-is made in compliance with San Joaquin Co.lnty Ordinance No.549 for sewage or No.1982 for wall/pump and the Rules and PA glrlatiorra Of the San Joaquin Local Health District. `g1 /n1 Job Address N-3 'J �t ► �c.q iZ A� � Lot Sipe PM Owner's Name Address 14 Contract `� c� �t` •^+ Addresses/fit'7 / Lkense 03 4 _ TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTICN ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O 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 C Industrial ❑ Open Bottom ❑Manteca Dia.of Wall Excavation Dia.of WM CaskV ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Tyco of using Spedficatbrr ❑ Public ❑ Other ❑ Deka Depth of Grout Seel Type of Grout C Irrigation --Approx. Depth ❑ Eastern Surface Seal IrtatsNsd by Repair Work Done _. Type of Pump ___ H•P• State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') Depth Filler M 1( 1 — TYPE OF SEPTIC WORK: NEW INSTALLATION❑ N DESTRUCTION❑ IND septic system permitted if public saws[is/ "able within 200 feet.) Installation will serve: Residence a Commercial_ Other Number of Irving units: _ Number of bedrooms t Character of soil to a depth of 3 feet: t ,�(�, Water table depth D SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C- Method of Disposal Distance to nearest: Well_ Foundation Properly Ime LEACHING LINE No. 8 Length of lines �'— yea Total lengthruza�7� ^ FILTER BED C'.:ante to nearest: Well_ Foundation — Property Lrna SEEPAGE PITS Depth _Size Number SUMPS Distance to nearest: Well_ Foundation_ Proprrrty Line DISPOSAL PONDS C 1 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 We...lance of the work for which this permit is lasl»d,I shah not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor•hiring or sub-contracting signattxs certifies the following: 'i certify that in the performr.ce of the work for v�;ch this purmh is issued,I shall employ persons subject to workman-s cm pence tion laws of Celifarnia." The applicaT must call for all required inspections. Complete drawing on reverse side. ( 1 Signed ! L1 I tL V < Title: c " Date FOR DEPAR ENT USE ONLY Application Accepted by _ Date Pit or Grout Inspection b Date Final Inspection by pats Addimnal Commenta: Stk 4666781 Lodi 369-3821 C Manteca 823.7104 ❑ Tracy W64386 Applicant - Return all copies to: Environmental Health Permlt/Servien 1801 E. Hazelton Ave., P.O. Bo:2008. Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTEDCASH RECrtED eV DATE rEMMIT NO. INFO �j