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k I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 f PERMIT EXPIRES '{YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 C Lot Size 57 X Yi pM I II � , Owner's Na a Address Phone _ V2-1 ca I Contracto Address f" 2 6 License No./ZS Phone -30-5/ 05 TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION ❑ = SYSTEM REPAIR-❑.: OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS x AL FLD. PROP. LINE FOUNDATION WELL OTHER-WELL- PITS/SUMPS INTENDED-USE- ---TYPE-OF WELL- PROBLEM-AREA -CON GTION-SPEGIHCATIONS. —�,"._ _ ❑ Industrial _ :- ❑'Open Bottom" ' ❑ Manteca- ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El 4 Type of Casing Specifications I'1 Public U Other eIta Depth of Grout Seal Type of Grout_____ 1.1 Irrigation Approx. til I i Eastern Surface Seal Installed by Repair Work Done ❑ Type ump H P - r State Work Done '* Well Destruction all Diameter Sealing Material (top 50') Dept o ' Filler Material (Below 501 - TYPE SEPTIC WORK: NEW INSTALLATION VI REPAIR/ADDITIONTI DESTRUCTION 1 i (No septic stem ,. 11 a p y permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other u k� Number of living units: [_' Number of bedrooms Character of soil to a depth of 3 feet: / ~ Water table depth SEPTIC TANK YJ Type/Mfg Cap Y No. Compartments acit 2=!.t, PKG. TREATMENT PLT. ❑'�` `,,method of Disposal Distance to nearest: Well Foundation—Si Property Line S r 1 LEACHING LINE No'l& Length of lines _�2 — 1ij ! e- _ f i*^ Total length/size I k0 A FILTER BED ❑ Distance to nearest: Well Foundation �� "'"e E Property Line' a SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest Well Foundation l ---.,� 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 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 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 applican ust call for all red inspections.n Complete drawing on reverse side. -� i Signed X Title: .: Date: )- FOR DEPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date nspection byte Additional Comments: I lb---" E) Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 Il FEE -AM DUE AMOUNT REMITTED CK I ENFO CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IREV.t/A 57 . _ .:.- aEH 14-26 LLL JE Q—ZS-� '" If •LAY r 'r