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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �.x "Telephone (209) 466-6781 } PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. , b Address O " y �'" "� L `City ot"Size PM rDISTANCE wner's Name 0 )b '�� Address `�" Phone OW1W �7 7 / L � ontractor Address 40� • O_Aoz License No.? `O "Phone PE 4 OF WELLIPLiMP: `e.. ` NEW WELL—�,,� 1NELL`REPLACEMENT,❑ - `DESTRUCTION-❑✓ `"' PUMP iNSTALLATIOIN ❑ SYSTEM REPAIR ❑ OTHER ❑TO NEAREST: SEPTIC TANK -SEWER LINESi DISPOSAL FLD. PROP. LINE , ; r 99 r S FOUNDATION i. f".AGRICULTURE.WELL � '-MOTHER WELL f" PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S �� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat Dia. of Well Casing A� � D.omesiic7Privafe -0 Gravel"Pack.....-�--' L]TFacy- �-^ ""Typ€of`Casing iy ""' `Specifications_„ ❑ Public Other ❑ Delta Depth of Grout Seal d pe of Grout ` "e Irrigation f .:Depth ID Eastern Surface Seal Installed by Repair Wok DoneQ. TYPe oPup H.P. _ State Work Do Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system'permitted if public sewer is E ».-�-.. .�� .... : �_. •,,._ ..,.-. "available within 200 feet.) Installation will serve Residence— Commercial_ Other " Number of livingunits: Number of bedrooms Character of soto a depth of 3 feet: Water table. gepth j SEPTIC TANK ❑ Type/Mfg Capacity i f No; Compartments PKG. TREATMENT PLT. LlI 1'J w{ Method of Disposal Distance to nearest: Well Foundation a Property Line i I LEACHING LINE 1 "❑ No. & Length Iof lines Total lengthlsize _ 4 � FILTER BED ] ❑ Distance to nearest:.—Wellv.- _---•-- --Foundation----—^^^---Property Line t SEEPAGE PITS ❑ Depth Size Number f f Y SUMPS i ❑ Distance to nearest: Well Foundation PrppertyrLine " ' . DISPOSAL PONDS 1 ❑ � I hereby certify that I have prepared this application and that the work will be done in accordance with,.San Joaquin cortinty ordinances, state laws,fand rules and re ions of the San Joaquin Local Health District. r Home own r or icensed agent's signature certifies the following: "I certify that in the performance of the,work:for which this permit is issued; I shall not employ an pens n in such manne as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies th fol) in ';I certify t t in the ormanc of the work for which this permit is issued;`f shall employ<persons'subject to workman's compensa-' C tion laws o C rfornia.' ;'" } The applica ust call',for Il r red ti ns. mpleta drawing on reverse sid ^" kr v Signed I Title: Date: ZLA FOR DEPARTMENT USE ONL-Ye Application Accepted by ti "Date• � .r Area S Pi or Inspection by. F'^ e 1" ' V� Final Inspection by �~pr s� T Date Additional Comments: .+ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 823-7104 ❑ Tracy 835-6385 Applica t� Return all copies o: Environmental Health_ „ y1Pe�nit/Sprvi s 1601 E. Hazelton Avea P _Box 2009, Stk A 95201 YZ- -;7tL t IFEE NFO AMOUNT DUE AMOUU CK NT REMITTED CASH RECEIVED BY DATE PERMITNO. GtZClI /to + EH 13-24 4REV.1 i n 51 i EH 14-26