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r n r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA F 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 y City 2 Lot Size a-49. . PM ,. 1 Owner's Name _ . _ ress Phone Contractor ddress7 License Na. / Phone /J yf r/G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ if,PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,4TO..NEAREST:ASEPTIC TANK SEWE LINES DISPOSAL FLD. ' "FOUNDATION AGRIC TUBE WELL OTHER WELL PROP. LINE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS ❑ Industrial 0"'4 ,j J"5+❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/ EJ Gravel Pack ❑ Trac Type of Casing Fl Public � ❑ Other Specifications f) elta epth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I I Eastern urface Seal Installed by Repair Work Done ❑ Type of Pump y P - State Work Done Well Destruction ❑ Well Diameter Sealing Mat ria) ftop 50') Depth Filler Materia! {t3etoyy ro0•I .R, ' TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is � l ' available within 200 feet.) Installation will serve: Residence--Commercial_ Other Number of living units: Number of bedrooms _. t= Character of soil to a depth-of 3 feet: SEPTIC TANK ad Water table depth ❑ Type/Mfg Capacity No. Compartments n PKG- TREATMENT PLT. ❑ {' i Method of Dispo -' r Distance to nearest: Welt J U ' Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 'O�bundation__�r� -- property Line [ -: k - SEEPAGE f.d i PITS I I Depth - Size � - SUMPS Number -t'' L71 Distance to near st: Well oundation DISPOSAL PONDS ❑ Property Line nd that the work will be done in accordance with Sa Joaquin county ordinanc I hereby certify that I have prepared this application a rules and regulations of the San Joaquin Local Healtti District. es, state laws, and Home owner or licensed agent's signature certifies the'following: 'T certify-tha empldy any person in such manner as to bt in therperforman Mthe work for which this permit is issued, I shall noecome subiect to workman's compensation laws of California."Contractors hiring or sub-contracting signaturet certifies the following: "I Certify that in the performance of the work for which this permit is is tion laws of California." sued, f shall employ persons subject to workman's compensa The applicant ust call forIlirequired inspections. Completi'draw_ing on,reverse side.,/ Signed X Title: *+ ', Date: .._ FOR-DEPART_MENTlU5E ONLY Application Accepted by Date ~ '"` )Area ''/� y Pit or Grout fnspection r ' _ by Date t Final Inspection by - Date' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 LI 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 t 7L' FEE AMOUNT DUE AMOUNT REMITTED CK rJ I INFO CASH RECEIVED Y DAZTjEPERMIT'NO. ,] +.£H 13-2 (REV.t/rs51 -£H 1A-2t1