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APPLICATION FOR PERMIT SAN JOAQUIN 66CAL HEALTH DISTRICT 1601 E. HAZE'"ION AVE., STOCKTON, CA Telephone (209) 466-6781- A PERMIT EXPIRES1 YEAR FROM DATE ISSUED - s -(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. 1062 for well/pump and the Rules and Regulations of the San Joaquin t Local Health District.- Job Address Ib,, �/ �-.A l .� �. �C%( , 1 City {� Lot SiPM �s ze 1 .# Owner's Name 1 � Addres ; / ,4 `t! s [1J L.Q_ L 1� G�-�f' Phone r°—r-Irrddress " 'b° iJ t �� / '�� LicenselVo.c�+ Oo(s�1a Phone �0-SdQS Contract ~ TYPE OF WELL/PUMP: >� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ '.PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ��1 DISTANCE TO NEAREST: ;SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE __FO,UNDA?ION-—AGRICULT.URE-WELL------.OTHER-WELL---- --PITS/SUMPS INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑,Manteca `D6: of Well Excavation,--' Dia- of Well Casing --r-Ca-Domestic/Private—EJ-Gravei-Pack-- ---❑-Tracy-""^`Tppe-af-Casing Specifications ❑ Public ❑ Other. ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 2, State Work Done Well Destruction ❑ Well Diameter Sealing Mate top Depth _ flier Materik(Below 50 < TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR ADDITION ;DESTRUCTION ❑ {No septic system permitted if public sewer is / available within 200 feet.i Installation will serve: Residence ,0 t Commercial— Other t Number of living units: Number drop s�. `Y I Character of soil to a depth of 3 feet: ; - r x x I Water table depth O 15- SEPTIC SEPTIC TANK ❑ Type/Mfg . t 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ o r i t i Method of Disposal , Distance to nearest: Well Foundation Property Eine LEACHING LINE ❑ No. & Length of lines ' l �' - I i_ Total length/size I FILTER BED ❑ Distance to nearest1 Well, "_ £"'-Foundation 1 + Property Line .rI y SEEPAGE PITS l Depth _Size; Number OC SUMPS ❑ Distance to nearest: Wjell__ (5 Q-�_.. Foundations Property Line DISPOSAL PONDS ❑ 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,_,,, Home owner or agent's signature ce ifies tfie,fdll w i g g �' � g: "I certify that in the performance of the work for which this permit is issued, I shall no employ any person in such manner as to become subject-to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"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 California." � ,The appiica ust call or 1111 eqAltecl,inspectlons. Complete drawing on reverse si 5ignad X Title: Date:CAA FOR DEPARTMENT USE ONLY r Application Accepted by t DateyjArea j. Pit or Grout Inspection by , Date Final Inspection by spate = Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 2`_ dVanteca 023-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24 iREV.t/e 57 _776, �j Q EH 14-28 -l 6,L?k� /�r•� O b �Z1 1 r .. �