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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA .4 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) e 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 Tom, eC416 City grl Lot Size `e 4cs- PM Owner's Name Address •�YfJ`O� PhonePhon Contractor's Name" — License No. TYPE OF WELL/P=P- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f \ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " 1h,,N DISPOSAL FLO. PROP. LINE FOUNDATION_ -AGRICULTURE W..•E LZ �F BOTHER WELL - -FITS/.SUMP-S-= INTENDED USE '�TYPE'OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS [IIndustrial ❑ Open,Bottom ❑ Mantec'a,� Dia',off Well:Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel-Pack ❑ Tracy Type of Easing Specifications.- + ❑ Public } El Other ❑ Deltas Depth of Grout Seal Type�of Grout: ❑ Irrigation I--,— __ Approx. Depth ❑ Eastern 'Surface Seal lnstalled_by. - — Repair Work Dorie ❑' 'Type of Pump —H-.P. State Work Done Well Destruc%tion p Well Diameter Sealing Material (top 50`1 Depth Filler' "'-- ler Material (Below 501 "I TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION WPITNo septic system permitted if public sewer is available within 200 feet.) i00 Installation will serve: Residence Commercial_ Other l• Number of living units: Number of bedrooms Character of soil to.a depth of 3 feet: sw*#y Water table depth 3 �9 5`T �'®kL'2� Capacity ��Q� No. Compartments SEPTIC TANK f �Type/Mfg, r PKG. TREATMENT PLT. ❑ (,d Method of Disposal Y Distance to nearest: Well Foundation Property Line ± (� l p _ LEACHING LINE �No.& Length of�•lines length/size Cin �Total len 9 FILTER BED ❑ Distance to nearest: Well Foundation f Property Line SEEPAGE PITS ❑ Depth Size Number �r.f SUMPS` 1.: ❑ Distance to nearest: Well Foundation Property-Line DISPOSAUPONDS 1 - ❑ ! 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 licensed agent's signature certffies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 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 applicant must all require inspect' omplete drawing.on reverse sides. Signed ' Title: S�"�T "'rte"2 Date: FOR DEPARTMENT USE ONLY Application Accepted by , Date r _ Area_ ' W� ' � � Date Pit or Grout Inspection by� Dae ��l Inspe 'on by Additional Comments:. 1 ❑ Stk 466-6781 ❑ Lodi 1 ff Manteca 823 04 � Tr y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. { + EH 13-24(REV.10/83) Ar--? ' EH 14-28_ -