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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT NOW 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v (Complete in Triplicate) Application is hereby 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 Ciiunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. iJ Job Address [71 ® 3 City Lot Size PM Owners Name �f/ `"a 3.Address Phone ! " C3 C7 / 7 Contractor Address License Na(33 Phone j/OK TYPE OF WELL/P1.10IF NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUM NSTALLATION ❑' k SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC NK SEWER LINES DISPOSAL FLO, PROP. FOUNDATI N AGRICULTURE WELL OTHER WELL PIT UMPS INTENDED USE TYPE OF WE PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications - fl Public n Other I - Delta Depth of Grout Seal Type of Grout I I Irrigation _ -Approxi Depth l I stern Surface Seal Installed Repair Work Done ❑ T rp p Type of Pum � H.P. State Work Done—3 Well Destruction Q Well Diameter Sealing Material /top , Depth T ler Material { w 50') k TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR DDI I I DESTRUCTION (No septic.system permitted if public sewer is + available within 200 feet.) Installation will serve: Residence J�' Commercial_ ther Number of living units: Number of bedroom + Character of soil to a depth of 3 feet! Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El r Method of Disposal t Di ce to nearest:'Well Found ion Property Line � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size -N ber SUMPS 0 Distance to nearest: WellFoundation "I Property Line I DISPOSAL PONDS ❑ � � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ardinances,'state.laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signatui a 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant n4w call for all re re inspections. Com a drawing on rev a side. Signed X Title: Date:a ZFCkQ DEPARTMIENT USE ONLY Application Accepted by ratite Date 3_11JZ Area Pit or Grout Inspection by Date Final Inspection bye IUD Date �– J Additional Comments: Dom -+ i T� f f p+ �'i-o Gq l r f" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 835.6385 Applicant - Aeturn all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦ EH11 -3-241REV.iiK5l • eV- �j/ EH t4-26 3'f V(AlJ 0 '