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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'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/pum and the Rules and Regulations of the San Joaquin Local Hearth District.: 2 r S Job Address City Lat Size •/� PM —lit J V/ i Address Owner's Nam. r Phone Contractor- Address �;/ License No.% Phone 1? ! TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑- r I. DISTANCE.TO NEAREST:_SEP.TIC._TANK.F--• SEWER LINES DISPOSAL FLD. PROP. LINE. I FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom C1 Manteca ' x'. Dia. of Well Excavation f]ra. of Well Casing ❑ Domestic/Private ❑ Gravel Pack f ❑Tracy Type of Casing Specifications f 1 Public, 4DOther ❑ Delta;, Depth of Grout Seal Type of Grout el I I Irrigation w �_ Approx. Depth I I Eastern � Su4ace Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �:- -Well Destiuctid 'D—wLili'Diartieier� "= � Sealing Material (top 501 /Depth � � Filler Material fB low 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION_ I REST UCTION l I INo septic system permitted if public sewer is liable ithin 20f1 feet.} {fes] _ Installation will see:, Residence__,Cpmmercial _^^ Ot.her ryt tts ,.Number of living units: "3 '= Number of bedrooms Y „a Water table de -Character-of;,soil'to a depth of 3 feet:' depth SEPTIC.ITANK ❑ Ty /Mfg.,. {°' t AF,2� Capacity d No. Compartments+Method of Dis alPKG.pTREATMENT PLT. ❑ p;Well �/ ation S Pro Dis#ante to nearest: pert- Line r 'LEACHING LINE ❑ No.'& Length of line 4 If Total length/size FI , - }LTEW BED ❑ Distance to nearest dation Property Line 1 SEEPAGE PITS I I Depth ize T. — Number SUMPS ` LJ Distance to nearest: If d n ftiProperty Line DISPOSAL PONDS P❑x. I hereby certify that I have prepared this application A that the work will be Kone in accordance with San Joaquincounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �' +� �' r ome owner or licensed age'ni:'s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not H } employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r certifies the followirig: "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 Califoihia. 4,7- The applicant st call for Fallre fired inspe ions: Complete drawing on revers.side. Signed X Title: ��/YLp��r' bate: ''�4, a 1 Jy. FOR DEPARTMENT USE ONLY 6 e _,T.Application Accepted by UP11 __ Date Area _ •Pit or Grout Inspection by Date Final Inspection by J Date f Additional Comments: r 177 Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104- _❑ Tracy 835-6385 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r } INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'`NO. y 1 +.E 4 70-241REV.iiHSf 11 ' EH 14-28 d V