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APPLICATION FOR PERMIT 0. ^� 5 ` SAN JOAQUIN LOCAL HEALTH DISTRICT f e 1601 E. HAZEL T ON AVE.,.STOCKTON, CA At" -Telephone (209) 466-6781 ,, Q� _ 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, (Complete in,Tripiicate)', .. , 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 H 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... ' Tfir sit . u Job Address f~7 , ' . l City Lot"Size, PM Owner's Name ..� +. �A-ddressf. ho e Contractor �'._ .�.--- s Address License No. TYPE OF WELL/PUMP: Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Eil PUMP INSTALLATION ❑ -SYSTEMIREPAIR-re DISTANCE TO NEAREST: SEPTIC TANK OTHER O SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL k V PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATIO4,NS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well Excavation"I I W -,❑ Domestic/Private ❑ Graver Pack ❑ Trac Dia. of Well Casing ❑ Public Y Type of Casing i)' I Q ] ❑ Other Sp11 cificatians r ❑ Delta Depth of Grout Seal I ❑ IrrigationType of Grout _Approx. Depth 7-1 Eastern Surface:SeaIAnstalled`b� �. Repair Wa ork Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter State Work pone_ !II Sealing Material {top 50'i Depth Filler Material (Below 50') e TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO stem(No-septic s a Y permitted if public sewer is Insta lation will serve: Residence` Commercial Other available within 200 feet.) q� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTICITANK L2 Water table depth Type/Mfg Ca?act ' N ' PKG. TREATMENT PLT. EF] o. Compartments Method of Dis osal Distance:to nearest: WellFoundation °i&N . � Property Line r LEACHING LINE Cl No. & Length of lines ' 7 FILTER BED T taLlength/size ; ❑ Distance to nearest: Well Foundation y Property Line _,! SEEPAGE PITS Q Depth F Size Numbr SUMPS # °^ ❑.. Distance to nearest: Wel! - & FI k Foundation .'Property Line DISPOSAL PONDS CI 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. 9Lk Home owner or licensed agent's signat�re certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not emplo11any person in such manner as_to become,subjectfthe to work-m_an'ssccompensatiiotoont taws of California."Contractor's hiring or sub-contracting signature certifies the followingm: "I certify that the performance c f work for which this permit is issued, I shall em tion laws of California." P Y persons subject to workman's compensa The ap licant mus call r all required " pectin Co tete drawing on reverse side. Signe !X Title: Date: l I FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or out Inspection by Date �. Final Inspection by Date 3 1-� i [!� Additional Comments: ❑ Stk 1466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 i ❑ Tracy 835 63gS n Applica t- Return all gples to: Environmental Health Permit/ ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE. .�. AMOUNT DUES^'"'....Ah0U__�. E'MIT—TED I TE INFO AMOUNT REMITTED 'CASH RECEIVED BY pATE-"'_1' +/p{ PERMIT NO. + EH 13-24(REV.I _�,s .r (J 7—'7X EH 14-28 ��JJJ r/ � - I