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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL 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/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address l� � i f1 f7; r' j City r Lot Size PM Owner's Name - {Jax Address �� „s; � �r r r, • ' / . �/� f/;� � Phone Contractsddress f J NEWTYPE. OF WELL/PUMP: License No. .[& Phoneq WELL WELL REPLACEMENT ❑ DESTRUCTION LlPUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -------- DISPOSAL FLD.� PROP. LINE FOUNDATION 7S "f AGRICULTURE WELL f��OTHER WELL o"PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation _ Di6 rf Domestic/ Private' r a. of Well Casing � Gravel Pack CI Tracy Type of Casing (r, 1"1 Public ❑ O er SpeciTica4ions(._i--- jh Ll Delta Depth of Grout Seal Type of hrout!�' `�011i' I I Irrigation ,; dW.Approx• De l Eastern - "' .-- - Surfac Seal Jnstalled by I C Repair Work Done ❑ Type of Pump H P Well Destruction Cl Well Diameter State Work Done r Sealing Material (top 50') Depth Filler Material (Below 50') = ~ TYPE OF SEPTIC WORK: NEW INSTALLATION Cl RLPAIR/ADDITION i I DESTRUCTIOflJ;ffQo eptic system permitted if public sewer is ?available within 200 feet.i Installation will serve: Residence — Commercial Other Number of living units: Number of bedrooms {( Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg— ;----='ater table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: Well Foundation Method of Disposal Property .Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS I I Depth Size SUMPS❑ DiNumber Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 Di§trict. Home owner or licensed 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 any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certifythat 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." p p 1 pensa- The applican _ all re tions. Complete drawing onr ver side. Signed — Date: ap F R DIPARTMENT USE LY Application Accepted by -- ��1�`0.� Date _ 1 lJ Area Pit or Grout Inspection by �` _bat Final Inspection by Date t � Additional Comments: .-_- 'ith, 466 6781 ❑ Lodi 369-3621 Applicic ant - Return all copies to: Environmental ❑ Manteca 823-7104 ❑ Tracy 835-6385 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - FEE AMOUNT DUE INFO AMOUNT REMITTED CK CASH RECEIVEp BY DATE EHy... ♦ EH 13-24 (HEV. 1/ w 51 U S a �/ (� 10.26 } C-T- PERMIT' y' /'y y �]% No. g ftp � / liI o r