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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.—JON AVE., STOCKTON, CA , Telephone (209) 466-6781 1 PERMIT EXPIRES 7 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. Cityalli�zLot Size y 1 PM Job Address y Owner's Name f Address Phone f `� " act ., ddress F r License No "ContraPhone�� TYPE OF WELL/PUMP: %' ,y 3;NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t Y DISPOSAL FLD. PROP. LINE + FOUNDATION AGRICULTURE;WELL OTHER WELL PITS/SUMPS INTENDED USE -TYPE OF WELL, Jk PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria F-1 Open Bottom ❑ Man t�ca Dia.``of Well Excavation o Well Casing ^-^_Y'"""` Specifications Ll Domestic/Private ❑ Grave El Tracy Type of Casing p Grout Seal , f+ Type of Grout ❑ Public+..�, t ❑ Other ❑ Irrigation.— ) ---Approx. Depth El _ eal Installed by �m"""^"'"""` Repair WorkDone— C] Type of PuHy:P. to e ` Well Destruction ❑ W ameter Sealing Material (top 601 Depth f Filler Material {Belo 60'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIONSTRUCTI ❑ (No septic system permitted if public sewer.is �I vailable within 200 feet.) Insti Y '•} _ allation will serve: I Residence_ Commercial, Other .. Number of living units:. Number of bedrooms ,k t ' a Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANKS +" ❑' Type/Mfg Capacity dr No. Compartments t 3� Method of Disposal ° PKG. TREATMENT PLT. ❑ tt .T, ; Distance to nearest: Well Q Foundation -'Property Line i v� LEACHING LINE � No. & Length of lines ' T tal length/size t Foundation l� Property Line FILTER SED � i� Distance to nearest: Wets {� t Number SEEPAGE PITS """ �"�' Deptli�x Size r SUMPS - ElDistance to nearest: Well ` Foundation..— P I is rty Line i .DISPOSAL PONDS ❑ t - } t 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 Lo'bAl.Health District. Home dwner 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 �erflploy any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature r 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 . i t 'tidn laws of California.' „- i —>. -w r The-applicant-must ca l for al re 'ed ins ctions. Complete drawing on reverse side. . . t Title: . s D� _ Date: )2 -3:% Signed W , I<^ Y FOR DEP RTMENT USE ONLY t i` 4 ! - a x33 5 Wit` Date Z J Area O i i lication Accepted by Final Ins 3, Date L Pit i r Grout Inspection by Date �. 4vi. dk) rfi u� d It �� i r+4 �-� � _ Additional Comments: 5tk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 11,46 - �f r "A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95201l 6F,- . j p .N r LK 5RECEIVE, DATE PERMIT'NO.INFO FEE AMOUNT DUE AMOUNT REMITTED CASH go157? EH 13.24(REV.1 i e s] EHf 14428