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# APPLICATION FOR PERMIT VV t t SAN JOAQUIN LOCAL HEALTH DISTRICT 'PIE CEM IV PED ' ,s L3 Ei 1601 E-.,,HAZEL TQN AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 6 19$9 (Complete in Triplicate) F� 1l1R"NMENTAL HEALTH r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta t eq r te�=K�application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the d San Joaquin Local Health Dist r ct. r r Job Addres i � of Size PM i Owner's Name A:i',^q!YA Address Phone me S Contractor Address 02 /7 Z License No1 B_Phone tj4612� I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑" OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PiSP05AL FLD. PROP. LINE ' „ INTENDED USE .TYPE OFiWELL PRIOBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bo[tom ❑JManteca Dia. of Well Excavation / Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack _QITracy Type of Casing , r� Specifications 1 FI Public Ll Other ;j Ll Delta Depth of Grout Seal f Type of Grout I Irrigation �� Apprt%Dep h i I E stern 5u ce Seal Installed by ( Repair Work DoneIts Type of Pump--, iH.P. State Work Done VJ r Well Destruction ❑ WellZiameter v 'I Sealing Material (top 501 % Depth 1.1.. 1 4 ~' " Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION_il.V' R)-PAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other `/r - ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Wa7ter table'depth SEPTIC TANK ❑ Type/Mfg I Capacity j ' '`i4o.;ICompartmgnts-� j s k PKG. TREATMENT-PL-T-0-.- �._ -t. -^--Method-of Disposal, t Distance to nearest: Well Foundation Property Line I 3 LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line — SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 15, 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 I se a is signature certifies the following: "I certify that in the peifformance of the work for which this permit is issued, I shall not employ any pe on in such m ner as to become sub" a workman's corlipansationitaws of California."Contractor's hiring or sub-contracting signature _ certifies the f Ilowing: 'a cartiA that in he o ce f e work for which this permit I issued, I shall employ persons subject to workman's compensa- tion laws of California." j' The applic t must c I r all re ife . Compl to drawing on r d . Signed X Title: FOR DEPARTMENT,S ONLY I Application Accepted by ._ 4 '"'�.�I Date}c`� i`' re s Pit or Grout Inspection by Dacu4_ �Final,Enspe, � I Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE k INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. +.EH13.24(REV.1 i x 5) EH 14-26 S fgig