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r 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. H;42EL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 'I ermit to construct and/or install the work herein described. Application is hereby made to the San Joaquin Local Health District for a pThis application is i made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weld pump and the Rules and Regulations of the San Joaquin Local Health District. City �✓ Lot Size PM Job Address ddress Phone Owner's Name t tr7T !it T`�ddress License No. Phone Contractor DESTRUCTION ❑ WELL REPLAGEMENT ❑ TYPE OF WELL/PUMP: NEW WELL SYSTEM REPAIR ❑ OTHF�R ❑ PUMP INSTALLATION �� `�" SEWER.LINES DISPOSAL FLD. �— ROP. LINE DISTANCE TO NEAREST: SEPTIC TANK -`T— _ "OTHER OTHER -WELL FOUNDATION'S'AGRICULTURE WELL' �r �r INTENDED USE TYPE OF WELL PROBLEM AREA'R CONSTRUCTION SPECIFICATIONS �pia. of Well Casing " ❑ Open Bottom l�.Man-.lata r Dia. of Well Excavation i ❑ Industrial - �'ti = Specifications -� ravel Pack L] Tracy -- Type of Casing S 17 Domestic/Private Type of Grout v I-1 Other C71 Delta Depth o1 Grout Seal I'1 Public - by ��-+�-->�--- Approx. Depth I Easternfi � ace Seal installed! I Irrigation Z^ State Work Done Repair Work Done ❑ Type of Pump � H''P,. r 5ealing_Material-Mop-5a'l�- Well Destruction L] Well Diameter ` €� r ! Depth _. Filler Material'(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION {] REPAIR/-ADDITION l I 'DESTRUCTION t )-availabllelc system w thin 200 feetled if public sewer is !I. Installation will serve: Residence— Commercial Other Z - Number of living units: Number of bedrooms . � _ - Water tabled pth Character of soil to a depth of 3 feet: >` ;r - , Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg �. - 5 Method of Disposal PKG. TREATMENT PLT. ❑ _' _ r j Distance to nearest:,. Wellfoundatidn Pro pert y Line ii �r n rw.t F" .r � /`. "` Total length/size LEACHING LINE LI No- & Length of lines Property Line ` FILTER BED El Distance to nearest: Well Foundation SEEPAGE PITS f I Depth size Number r- I SUMPS LI Distance to neatest: Well Foundation Property Line 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 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 to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: 1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa r tion laws of California." The applicant o all re ions-Complete drawing-on reSe�ecsi9 t / f �Title� ?.Date: Signed X !� TOR&DEPARTMENT USE ONLY I Date Area l Application Accepted by �� pate �� k 4 at Final Inspection by Pit orO ut Inspection by { _ Additional Comments: I .0-Stk-466-6781. -_rd-Lodi,._.369-362-1-4--�.- -❑-Manteca--823-7104- -�©Tracy-835 6385 .„ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 I -,- ,� �, �, 't f CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH r INFO r.EH 13-24(REV.t/n Eo IN O �r./ r ♦� .` + �f/ F EH 1429 ty Q P ( L