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f � DAPPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D 1601 E. HAZEL T ON AVE., STOCKTON, CA S�Q Z 6 Isga Telephone (2091 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED pNME`��P�� SCS SH (Complete in Triplicate) Nvp�[2M 15EC�V Application is heieby 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1- , Job Ads (. dres `" 03 +'�"'��` P4 CityLot Size PM Owner's Name � � Address if .a_�, Phone Contract Address.Address rQ License Ho.j Phon TYPE OF WELL/PUMP: ` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR'❑ OTHER ❑ .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJOpen Bottom ElManteca Dia- of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M l .Public 1 1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation IhApprox. Depth 1 l Eastern S riace Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done p Well Destruction ❑ Well'hDiameter Sealing Material Itop 501 1 Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION 1 l DESTRUCTION I I (No septic system permitted if public sewer is I :!I. available within 200 feet.) Installation will serve:. Residence_ Commercial— Other Number of living units: 1. Number of bedrooms Charer of soil to a depth of 3 feet: Water table depth act __E�Ey SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:' Well Foundation Property Line LEACHING UNE ❑, No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J 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 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re iced inspections. Complete drawing on reverse side. Title- FOR � Date: g-cg- + Signed X. FOR DEPARTMENT USE ONLYi, k Application Accepted by it Date '" Area I� it � Date ' Pit or Grout Inspection by Date Final Inspection by Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i� "rr-FiE7 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 7 3 +.Eli 13-24 tr1EV. n sY L �I &- �"'S 9 EH 1I-26 II