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apa APPLICATION FOR PERMIT � . �f JOAQUIN LOCAL HEALTH DISTRICT SAN - i 1661 E. HAZEL i ON AVE., STOCKTON, CA i Telephone 1269? 466-6781 PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) is heieb made to the San Joaquin Local Health District for a permit Noo 1862 construct or and/or rrlinstall th and the Ruoles andrk 'Reguati-n is lations o1'hhe San Joaquin i Application Y Joaquin County Ordinance No.549 for sewage made in compliance with San Local Health District. , Q,( f? �' Lot Size QL PM r � City � Job Address t`�a Phone Address Owner's Name �� Contract � /! Z� Phone_ (��Address v License No. !ZJA?� emd W DESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT 11 – TYPE OF WELL/PUMP: SYSTEM REPAIR_❑ OTHER 17PUMP..INSTALLATION.O- SEWER,LINES _��-- DISPOSAL FLD. PROP. LINE I DISTANCE TO NEAREST: SEPTIC TANK !OTHER WELL— INTENDED FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM.AREAr` CONSTRUCTION-SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑_Open_Bottom_ ❑_Manteca Dia. of Well Excalation t �_ �'� T a of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ )racy Type Type of Grout i' - l. Other ❑ Delta Depth of Gout Seal / l Public, f ti}.Ci�v x.�,s -'"'"'�� '�- _...prox. Depth i I Eastern Surface seal installed by 1 I Irrigation State Work Done Repair Work Done ❑' ''Type of Pump H.P. Sealing Material (top 50'1 Well Destruction i ❑-+ Well Diameter '11 Material (Below 50'1 Depth TYPE OF SEPTIC WORK NEW INSTALLATION I l EPAIR! DDITION DESTflUCT10N I l lNo septic system permitted it public sewer is available within 200 feet.) Installation.will serve: Residence_ Commercial Others— 4 t -i� Number rooms '° I j Number ohiving units: Water table depth I µ Character of soil to a depth of 3 feet: No. Compartments F Capacity SEPTIC TANK ❑, Type/Mfg CapMethod of Disposal l PKG. TREATMENT PLT. ❑ Property'Line 1 t Distance to nearest: Well Foundation .�� l LEACHING LINE ❑ No. & Length of lines Total length/siz _ .e 'h Foundation Property-Line FILTER BED LJDistance-to nearest: We'll•' Depth, size Number' SEEPAGE PITS Property7Line l SUMPS Ll Distance to nearest: Well undation DISPOSAL PONDS ❑ ' x I hereby certify that I have prepared this application and that the work will be",•done accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. * Home owner or licensed agent's signature certifies the following: "I certify that in he performance of the work-far which this permit is issued, I shalt not r employ any person in such manner as to become subject to workman's compensatiomlaws of California."Contractor's hiring or sub contracting signature certifies the followin I certify that in the performance of the work for which this-perm4+is issued: I shall employ persons subject to workman's compensa- g: ' tion laws of California." The applicant t call for uir inspections. Complete drawing on revers t 1�- Date: Signed `Title: 111 FOR DEPARTMENT USE ONLY Date y Area - Application Accepted by , I ()-� r Grout Inspection by Date Final Inspecti n by Date= F. Additional Comments: If ❑ t466 6781 © Lodi 3Fi9 3621 ❑ Manteca 823-7104 El Tracy 835-6385 lth Permit 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 Applicant - Return all copies to. Environmental Hea i I GK RECEIVED BY DATE PERMIT NO. nZ!H= ED CASH+ EH 13-24{REV.t/n 51 L EH 14-26 -