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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED {Complete in Triplicate) s Application is heFeby made to the San Joaquin-Local Health District for a permit td 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. r� Job Address / +° ` Cit ,Lot Size 5 ��"� . PM �} Owner's Name � Address Phone CWS r �_Idess r� Licensontrato TYPE OF WELL/PUMP. FNEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST M REP R ❑ OTHER ❑ DIS ANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE It F # FOUNDATION AGRICULTURE W'.ELOTHER WELL ° PITS/SUMPS k INTENDED USE TYPE OF,WELL a PROBLEM AREA'IaCON UCTION.SPECIFICATIONS El Industrial : ❑.4pen Bottom �,- E] Manteca- Di of all Excavation i Dia. of Well ❑ Domestic I Private ❑ Gravel Pack= ❑ Tracy Mf pe f Casing-- � � Specifications; 6 Public FI Other E� `^ fl Delta`" DeptFi of-Grout Seal_ "—`' ' -,Type of Grout I I Irrigation" —.Approx. Depth_ I I Eastern-,#j,.-_.._.Surface Seal Installed by,__ d 4 { Repair Work Done L3 Type of PuFnp . 'ate `H.P. ' State Work Done Well Destruction _ ❑ Well Diameter Sealing Material Stop 501 3 -� -• �µ j T Depth Filler Material (Below 501 _ a TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION l 1 DESTRUCTIONS 1-(No septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence._'=t/Commer ial— Other Number of living units: Number ofrbedroorns R Character of soil to�a-,depthrof 3 feet: Water table depth SEPTIC TANKS a'O Type/Mfg Capacity ' No. Compartments PKG. TREATMENWPLT. ❑ Method of Disposal j Distance to nearest: Well SQ nor.r-_ Foundation _ Proparty.Line LEACHING LINE ❑ No. & Length of lines To I length/size' i FILTER BED ❑ Distance to nearest: Well oundation _� Property Line A G SEEPAGE PITS l I Depth 21 ItSize Number € SUMPS ❑ Distance to ne rest: Well oundation rd : Property Line d -DISPOSAL PONDS ❑ r - 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-regulatidns of-the San Joaquin Loca! Health Di fricf"'�'T""�"" i Home owner or licensed agent's signature certifies the following: "! 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 required nspections. Complete drawing on reverse side. Signed X e Title: _ ,t /j� _ ____ Date: c FO DE RTMENT USE ONLY Application Accepted by _ Date G l/7 C f Area P' or Grout Inspection by ate r f Final Inspection by u u 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦.EH EH 1428 14-24(REV.F/n sS .,Ott � i 1 -