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APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 456-6781 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 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 ,' 1 W F City Lot Size PM ' Owner's-Name v- — Address �((/ _ Phone /- 7,31-23? Contract r 7. ' I ,Addressr� 1 License,No Phone TYPE OF WELL/PUMP: NEW WELL ❑, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ 41 OTHER ❑ DISTANCE TO. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE A. FOUNDATION AGRICULTURE WELL ,OTHER WELL PITSISUMPS ti4F I INTI ND D l3SE`s+ TYPE OF_Yy-&l PFtO8`LEM.AREA......CONSTRUCTION S_PECIFICATIDNS ❑ industrial ""� I� 0 n Bottom ❑ Manteca t., Dia, of Well Exeavatiiors Dia. of Well Casing + ❑ Domest0kivate �'6ravel 'Pack" ❑-Tracy;� Type nt- n9 Specifications �, _ th,of Grout S al Type,of Grout _. M Public ❑ Other FI Delta,. Dep - A rox. Depthz. t I Eastern Surface 5aal_ljstalled by I I Irrigation ` -- PP e a. H. State Work Done— Repair Work 17one ❑ Type of Pump tNa Well Destruction ❑ Well Diameter S�ealing Material (top-5 4 Depth filler*Material�[Beiow 50'1 ' ` TYPE'OF SEPTIC WORK;``NEW INSTALLATION K REPAIR/ADDITION IESTRUCTION I I (No septic system permitted it public sewer is 7 available within 200 feet.) �J Installation will serve: Residence Commercial_ Other Number of living units: ; �_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth c e SEPTIC TANK Type/Mfg Capacity 0� No. Compartments .. f Method of DisposalosalPKG. TREATMENT PLT. © _ s _ .r Distance to nearest: Well � Foundation�— Prope7ty Llne .- A LEACHING LINE Fl"�No. & Length of lines S Total length/size Q FILTER_BED ❑ Distance to nearest: ' Welles foundation Property Line <J SEEPAGE PITS 4� fF?"'Depth (4 5 Size � f�lumber SUMPS L1 Distance to nearest: Well Foundation 0 Property Line DISPOSAL PONDS ❑ v - 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 _ j 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, l 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 applicant rruyq,call for all r ulread i sp�e�ctions. Complete drawing on reverse side. Signed X ` '��'�{ - 4 Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r Area it r Grout Inspection by Date � ~/ Final Inspection bbyp "Date Additional Comments: �_❑_Stk,,,;,466-6781 _;.__- ❑.Lodi_369-3621 _.—0-Manteca-.823-7104 _01-racy .935-6385- Applicant- Return all copies to: Environmental Health.Permit/Services-1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24IREV.I/H ) -7r/� ,0� EH 1428 .