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APPLICATION FOR PERMIT S-�- .__,,,•� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA t Telephone (209) 466-6781 �,,�,��11,��a.Q+�••Y� PERMIT EXPIRES 'I-YEAR FROM DATE ISSUED (Complete in Triplicate)I ' 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 i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. i- 4. Job Address r p } z, City Lot Size jPM Owner's NameE Address �0"E� �, Phane Contractor jr 'S� /�Ljf, �MC Address i36XS-/.Z License No. .zg Phone TYPE OF WELL/PUMP: NEVI/'-WELL O WELL'REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ " SYSTEM REPAIR C1 OTHER ❑ DISTANCE TO NEAREST.- SEPTIC TANK j .- � SEWER LINES DISPOSAL FLD. PROP LINE 't FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ j .INTENDED USE ;TYPE OF WELL-�.�PROBL-EM AREA CONSTRUCTION SPECIFICATIONS #❑ Industrial ❑ Open Bottom R ❑ Manteca Did-of Well ExcavRi6n 'r Dia. of Well Casing k 'Domestic/Private L1Gravel Pack 1-1Tracy Type of Casing Specifications ❑,Public ❑�Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation #Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump' : H.P. State Work Done_ t Well Destruction ❑ Well Diameter t Sealing Material (top 501 f Depth Filler Material (Below 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is �t c # ailable within 200 feet.) ` Installation will serve: Residence Commercial_ Other Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet: 4 Water table depth ' SEPTIC TANK Type/Mfg I ; Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No!&.Length.of lines Total length/size FILTER BED ElDistanceAo�nearest: Well Foundation m Property,Line SEEPAGE PITS ❑ E Depth Size Number + „l I SUMPS ❑ Distance'ta!nearest: —tWellfoundation" """ "' Pro tyLine i 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. I L Home owner or licensed agent's signaturel'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'sihinng 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." t The applicant t call far required i pections.Complete drawing on reverse side. Tfii Signed Title: } Date: /� a a - tt FOR DEPARTMENT USE ONLY f g., ' D *Application Accepted by Date Area Pit or Grout Inspection b ;.. 1. u date Final-Inspecticirf by.___.. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0-'Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health`Perrrmit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 1 N f f t FEE AMOUNT DUE t ,MOUNT REMITTED CK* —�'_]- -"CASH ,.:�-RECEIVES 8Y; �O/ATE_ ��. iPERlVl1?NQ, + 13-24 �V EH 14-26SREV.t/05Y -