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APPLICATON FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR 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. 0 & r 2? . Job Address City Stc&xot Size PM Owner's Name f• Address Phone Contractor Address • &OaC.Aq icense Nol 10 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR k OTHER Eli DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OT6 ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing — _E]--Oomestic/-Private...._ i❑ Gravel.Pack-_L]Tracy..._._._,..,,,....,.,Type of Casing r I Specifications �Q Public ❑ Other Cl Delta Depth of Grout Sea! I Type of Grout I I Irrigation 4 --Approx. Depth l I Eastern., R Surface Seal installed byAce X—m-M 1 Repair Work Done 0 Type of Pump H.P.'-• State Work Done Well Destruction ❑ Well 1A) Sea i(ng Material (top 50') ""' A I i Depth * Filler Material )Below 501 s : j TYPE OF SEPTIC WORK: NE INS ALLATION I'] REPAIR/ADDITION l I DESTRUCTION i IP(No septic system permit d if public sewer is .� ' p available within 200 feet.)1. Installation will serve: Residence— 'Commercial —Other— --4 � Number of living units:L—/ Number of bedrooms Character of soil to a fiepthlof 3 feet: Uzi ~` 1/Vater EIRMAn r SEPTIC TANK t (-]I Type/Mfg + '` 'f '� Capacity ! `t- r5o. CrED `1 PKG. TREATMENT PLT. ❑; ( 3 Meth �l ol` ."Distance newest: Well —.Foundation Property Lin "�..✓" 'l SANJOAOUINCOIINTY LEACHING LINE Cf"wato. & Lendilh of fines Toial len LIC HEALTH SERVICES tr f P HEALTH DIVISION FILTER BED.;;. .. ;, _© -Dijtance. to nearest: WO rr Foundation } Property Lme SEEPAGE PITS I 1 Depth Size _ Number I SUMPS LiZDistance to nearest: Well _ Foundation Property Line DISPOSAL-PQNQS._---❑ I. a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin counfy ordinances, state laws;-and ' rules and,regulations of the San Joaquin Local Health Diltrict. „Homeowner 4 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.tfoting: uch manner as to become subject to workman's compensation laws of CAlifornia." Contractor's hiring or sub-contracting signature certifiesI certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law " The appfo a re fired ins ns. Complete drawing o e r e side. r " Signed Title: Date: _ 1 i FOR DEPARTMENT USE ONLY Application Accepted by Date�G� 4 Area V)N' �J Pit or Grout Inspection by Date Fina{ inspection by Date Additional Comments: F (� 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., .0. Box 2009, Stk., CA 95201 r�{� PEE AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED BY DA7E PERMIT'NO. c +�EH 13- IN IREV.w/H 5] EH 14-26