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OU APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT �- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. /(/ .J� b -7 1 �3^ '/ ' 1��t V}j /`� Lam[ Lot Size� �R"'� PM f� Job Address City -e C-A Address �/ /�.rN1:/�' ; PhonT 1 �� r KOwner's Name 1 r y 116 P(Contractor aEril+!Y Address License No. Phone_ A' ` NEW WELL ❑" _ WELL"REP.LACEM T ❑.."� ". _'DESTRUCTION El TYPE OF WELL�PUM�: PUMP INSTALLATION ❑ SYSTEM PAIR ❑ W' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FED PROP. LINE FOUNDATION AGRICULT E LL OTHER WELL—$ PITS/SUMPS U INTENDED USE, , .TYPE OF WELL PROBLEM AREA a STRUCTION SPECIFICATIONS�yI > ❑ Industrial �+�„❑ Open Bottorn '> s7_M_�nteca t'.k' i 'oi INeII Exc_avat!on •�r mmj Dia. of Well Casing >r _tel `` Cn� . Specifications 4❑ Domestic/Private P Gravel Pack ❑ Tracy 7yp of Casing 51 , ❑ Other CI Delta Dept of=Grout Seal ` Typo of Grout ? a `l Public"c r` _ - f I I Irrigation —Approx. Qeplh I ! Eastern Surfac 'Seal Installed by fi a t'� Repair Work Done ❑ Type of Pump H.p State Work Done , Well Destruction ❑ Well DiameterSealing Mat®iai-fto 501 x # ~r t ' Depth Filler Material (Below 50'1 — "\ TYPE OF SEPTIC WORK: NEW INSTALLATION `;REPAIRIADDITION I I F DESTRUCTION l I (No septic system permitted if public sewer is ✓ i _ s� available within 200 feet.) Installation will serve: Residence! Commercial— Other ` Number of living units: � Number of bedrooms �-7 f{ Character of soil to a depth of 3 feet: __T4L� Water tabtedepth o-G SEPTIC TANK Type/Mfg Capacity o. Compartments JR f _ PKG. TREATMENT PLT. .�, F „ Method,of Disposal ❑ G �! Distance to nearest: Well {�® Foundation Propertykt Line •` f µ LEACHING LINE No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well j FoundationrQ Property Line i SEEPAGE PITS I 1 .Depth 44 Size__ t Number SUMPS Distance to nearest: Well� Foundation' j0 Property Line t " t € DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be donee n accordance with San Joaquin county ordinances, state laws, and f 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 ation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workman's compens 4 certifies the following: "I certify that in the performance of the work for which this parmit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." ! a r .A The applicant lmust _,call for all-required inspections. Complete drawing on reverse side. � /� ; /�(4� 1 f!�� `�'l'�– -- Title: w IJP' Data. R ° \igned X r TMENT USE ONLY r � � 1 v Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by \. Date– � I Additional Comments:, ❑ 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 FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO, i f* t INF '��'�� jf�� I j} + EH 13-24(REV.1 i N 5) : ___D ;7Z9, v �� 3/7 EH 14-28 :+kA * 1 „j ' 1 ye} �� 1 ? .. s i • ,: r M