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wr. APPLICATION FOR PERMIT t' SAN JOAQUIN LOCAL HEALTH DISTRICT �I1�2.12s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 fo"r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. F A Job Address City Lot Size PM Owner's Name � •" Cr Address r "1 " I` Q Phone Contractor , �yddress - License No.. Phone TYPE OF WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR M. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' rDISPOSAL FLD._ PROP. LINT: �^ -- .FOUNDATION^ --�-AGRICI•ILTLiRE- EL-L-- O7FIER-WE-L-L ------PITS'/SUMPS��- "--"--- ' . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i ' + Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac TCasing- Specificationsr V Y Type of F] Public �..•.--,.h..,,,,- _...u......,.,..,,...___r....�:�. C1 Other 1-1 Delta Depth of p of Grout I ! Irrigation _--Approx. Depth.^'.L.I_Eastern-._ Surface Seal Installed by f Repair Work Done ❑ Type of Pum F ! t p H•P• ' T Slate Work Done _ Well Destruction ❑ Well Diameter C Sealing Material Itop 50'1 i Depth I Fillervaterial(Below 50'l I � TYPE OF SEPTIC'WORK:- NEW INSTALLATION I-1 REPAIR/ADDITION 1 1 ' DESTRUCTION INo septic system permitted if public sewer is r available within 200 feetJ !� Installation will serve:' Residence Commir�ial�,' Othdr_ .^ Number of living units: umber of bedrooms "r " ' � �Y Character•of soil to.a depth of T1.feet: 1. Water..table depth .SEPTIC TANK'. ❑ Type/Mfg s` 'C$pacity`� %li F . No. Compartments { PKG. TREATMENT PLT. ❑ r, l ..- � � ' -sit �.,,�� s j I e< ; ,Method of Disposal Distance to nearest: Well 1 Foundation Property„Leine . LEACHING LINE ❑ No.'& Length of fines Total length/size c FILTER BED ElDistance to nearest:, we/, fFoundation Property----. � Line r a SEEPAGE PITS 11 Depth. "'Sizzems" Number + SUMPS D Distance to ne'aret3— '(Nell” -° Foundation W �' �Proper[y'tine"' < -DISPOSAL PONDS ❑ x 1 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 io become subject to workmad's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that•in the performance of t work for which this permit is issued, f shall em to tion-laws of California." P Y Persons subject to workman's compensa The'applicant mu II fo a taquired ins 'o Complete dr wing on reverse side. Signed X / Date: itle:� - 1 ._ FOR DEPARTMENT USE ONLY Application Accepted by Data �(r aJ .,.— Area Pit or Grout Inspection by Date Final Inspection by { Date Additional Comments: ❑ Stk 466-6781 r: ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUVTDUEINFO AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t i n sl EH 14-28