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�'. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 x•' PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct andlor instal{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 1 Local Health Districl.��yr�� ►.G+ ' ,� ✓ 4�'3� �S C76 IGUC� City Lot Size '-PM Job Address (�//� 7,`" Address r•��'-x �3�� / Phorie �S Owner's Name � - - �* -_3411 Contractor Address �L`cler �no. Phone 4 TYPE DF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I - ..-;', — u_ •- PLU-J P INSTAL,L'_.ATIO -❑ SYSTEM,REPAIR"❑ Tf�ER'7 Q r° ! DISTANCE TO NEAREST: SEPTIC TANK r,'1 SEWER LINES �~" DISPOSAL FLD, I� PROP. LINE FOUNDATION AGRICULTURE WELL: �� OTHER WELLS ?ITS/SUMPS INTENDED USE ��TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial�---�- P r ' Y -.� Type of Casing Specifications omesuclPrivate ❑Gravel Pack ❑ Tracy YP r >~ �' [tl Other. p -moo „ _ ' f`] Public Cl Delta Depth of Grout Seal �/l4 Type of Grout i ' I lrrigat+ors"`"" Approx. Depth I 1 Eastern Surface Seal Installed by . Repair Work Done ❑'Type of Pump H.P. State Work Done T Well Destruction 'E7 Weil Diameter Sealing Material atop 50'1 - `j Depth Filler Material )Below 50'1 - e I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I ;DESTRUCTION ! I (No septic system permitted if public sewer is , available within 200 installation will serve: Residence— Commercial_ Other Number of living units"-tf Number of bedrooms Character of soil to a depth of 3 feet: Water.table depth . aft t SEPTIC TANK �❑ Type/Mfg Capacity No. Compartments ,,, Method of Disposal' ~ �^ PKG, TREATMENT PLT-0 r Distance to nearest: Wel Foundation Property Line f s ' LEACHING LINE 171No. R Length of Ii € Total lengthlsize 1 FILTER BED El Distance to n est: Well Foundation Property Line t � ° SEEPAGE PITS l I Dept Size Number ISUMPS L] ce to nearest: Well FoundationProperty Line 4 l DISPOSAL PONDS ❑ i I hereby certify that I have repared 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 i the performance of the work for which this permit is issued, I shall not I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i Ic ertifies 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- e tion laws of Calif rnia." The applicant {red ins omplete drawing on ZHese s . f. # _ Z$1 k Title: date: Signed X + } -FOR-DEPARTMENT"USE ONLY f Application Accepted by Date Area Pit or ut Inspection,by � Date�:� Final Inspection by fff} Qir Additional Comments: cy ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LJ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Sox 2009, Stk., CA 95201 ! CK EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO: INFO �.EH 13-21(REV.i/B 5) n _ - EH 14-26 '' 7.