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APPLICATION FOR PERMIT �� a SAN JOAQU IN LOCAL HEALTH DISTRICT O 1601 E. HAZELTON ON AVE., STOCKTON, CA 26 Telephone (209) 466-6781 SrGP PERMIT EXPIRES 1YEAR FROM DATE ISSUED 0004 pAj��kc�s (Complete in Triplicate) LN I Application is hereby made to the San Joaquin Local Health District for a permit to constuct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18621 1 or well/pump and the Rules and Regulations of the San Joaquin Local Health Distrrict. I Job Addres—v—`,40.3 L City Lot Size PM II " Owner's Names Address Phone Contractor> Jz Address ,License fyo.T Phan TYPE OF WELL/PUMP: } NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR"❑ OTHER ❑ "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. POOP. LEVE FOU 1NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing No Domestic/Private ❑ GCavel Pack ❑ Tracy Type of Casing Specifications M Public (_I Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _IlApprox. Depth 1 1 Eastern S riace Seal Installed by �I H p State Work Done Repair Work Done ❑ Type of Pump Well Destruction El Well,hDiameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is 11. 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: WatLr table depth Capacity— SEPTIC TANK" LI Type/Mfg �,.No. Compartments PKG. TREATMENT PLT. ❑ f` Method of Disposal Distance to nearest:' Well "' Foundation Property Line LEACHING LINE ❑ f o. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 District- �. Home owner or licensed agentjs signature certifies the following: "I certify that.in employ any person in such manner as to become subject to workman's compensation perfonnanca of the work for which this permit is issued, I shall not ion laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I cartify 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.11reloluired inspections. Complete drawing on reverse side. p . — -Title; �-i Date: g_t ! Signed X. FOR DEPARTMENT USE ONLY Application Accepted by II Qate Area Pit or Grout Inspection by II Date Final Inspection by Date ' Additional Comments: ❑ Stk 466-8781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a1 i FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"N0. r"EH 13-24(REV.I/n h)[7 EH N-2s V