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I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county or - -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 p employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject `tion lawsof California." The applicant mu it call for all required inspections. Complete drawing on reverse side. Signed X Title: A �� Date: _ FOR DEPARTMENT JJSE ONLY Application Accepted by- Date `� �� —,+ Ll Ar Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1324 [REV. 10/im EH 1428 r nces, state laws, and nit is issued, I shall not b -contracting signature workman's compensa- Ze Date FEE INFO FA AMOUNT DUE APPLICATION,FOR PERMIT SHCK SAN ,JOAQUIN LOCAL,HEALTH DISTRICT DATE 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) r - 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 compiiance'with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 10 fyli 4 ,Q � 54 � %{ ��E�- I° I Job Address 1... ! xA rfi' 'OPT City Lot.size PM --4. i1 fi-.S Address I �D �ii%17 �f` Phone,fs� Owner's Name /�'� Q / O`'"l"" e C ' k/0005 la U 7� Contractor's Name License No. _ _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 9 FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing - f Specifications El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout p Irrigation - :SD Approx. Depth ❑Eastern Surface Seal Installed by 11' Repair Work Done ❑ Type of Pump H.P. State Work Done it Well Destruction Well Diameter Sealing Material {top 501 212 e 4 e Depth Filler Material (Below 50') ��- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTICseptic system permitted if public sewer is ..-ilable within 200 feet.l i 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I! I 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 I� SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county or - -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 p employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject `tion lawsof California." The applicant mu it call for all required inspections. Complete drawing on reverse side. Signed X Title: A �� Date: _ FOR DEPARTMENT JJSE ONLY Application Accepted by- Date `� �� —,+ Ll Ar Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1324 [REV. 10/im EH 1428 r nces, state laws, and nit is issued, I shall not b -contracting signature workman's compensa- Ze Date FEE INFO FA AMOUNT DUE AMOUNT REMITTED SHCK RECEIVED BY DATE PERMIi'NO. /C�Al/v—