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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON. CA Telephone 1.091 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hweby made to the San Joaquin Local Health District for a permit to construct and/of Install the work herein described.TMs application is made in eomplicnee with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of into San Joaquin Local Health District. pn _ ��3 S Lot Size PM Job Address y^�— Clty - nd irrss Phone - -,�g��y.-e _ _ _ I Owner's Nanw CC,tractor _ sL �-��t__ Address [�rJju- "'I License No ��'�'—Phone �� Y_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION Ci PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 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_ [IIndustrial U Open Bottom C1Manteca Dia.of Well Excavation Dia. of Well Casing WZnompstic/Private LI Gravel Pack ❑Tracy Type of Casing Specifications I'1 Public ( Other n Delta Depth of Grout Seal _ Typo of Grout I I Irrigation _Approx. Depth � �I I Eastern ,!.Surface Seal Installed by -- — Repair Work Done U Type of Pump gyp. H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') --- -- Depth Filler Material(Below 501 } TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (Nose ttic systithinem rMiit'ed if puobc sewer is availab-• 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 _ Capacity No. Compartments SEPTIC LANK U Type/Mfg PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE ❑ No.&Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I Depth --Size_— _—_ Number_ r' SUMPS f • Distance to nearest: Wrll _ Foundation Properly Line DISPOSAL PONDS 17 I h?reby certify that I have prepared this application and that the work will be done;n accordance with San Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health Diltrict. s the following:"I certify that in the performance of the work for which this permit is issued,I shall not Home owner or licensed agent's signature certifie 1 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion law,of California." The applicant rust cal f r all regYrq inspections. Complete drawing on reverso side. ( Title: Date: r Signed X_ -- DEPARTMENT USE ONLY Application Accepted by — Date Area _ ta_ Final Inspection by— Date I- �-I P-t or Grout Inspection by Da 1 j Additional Comments: 1i O Stk 466 6781 C Lodi 369-3621 C Manteca 823-7104 ❑ Tracy 835-6385 Applicant -Return all copies to: Environmental Hoalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE CK o RECEIVED BY DATE PERMIT•NO. INFO AMOUNT DUE AMOUNT REMITTED CASH .EH 1?24rREV iin'•il _� EH 14 26 L— ._..v....K.,:..:-......:...�.uwii n w,.,.w N��2S!•::+f'.`4 f-iR9:SiAkib:MwR`�+:un A .f y