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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT }` L 1601 E. HAZEL.T ON AVE., STOCKTON, CA Telephone {209} 466-6781 �1 I 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 t Local Health District. Jpb`Address �Q �' �i �i46wr City vv Lot Size Q�� PM Owner's Name la�'�f �i1.�1`I�I� Address ✓2 / ��►`�i'�✓QT� �I� Phone li I� ii Contractor l / friJKlll�f7 I iRdldress G/�^m L�lL l7 Y License No. le INGJ' Phone �Zo �i TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ t SYSTEM REPAIR ❑ OTHER ❑ �! DISTANCE TO NEAREST: SEPTIC TANK SFWER'LINES DISPOSAL FLD. PROP. LINE /ro i /FbUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS- INTENDED ITS/SUMPSINTENDED USE yTYPE OF WELL PROBLEM AREA CONSTRUCTION S F ❑ Industrial ❑i Open Bottom 1 Manteca eA_Excav_ation_ _ —Dia.-of-Well-Casing 1 ❑ Domestic/Private ❑f Gravel Pack a JTr Type of Casing Specifications Il 0Public 'Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation 11 ox, Depth ❑`Eastern Surface Seal Installed by Repair Work Done. f ;. p re of Pump I H.P. State Work Done Well Destru ❑ Well Diameter i Sealing Material (top 50') 1 Depth I Filler Material (Below 501 I F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑; REPAIR/ADDITION ❑ DESTRUCTION "(No septic system permitted kf public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: �M Nurnber of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑I Type/Mfg Capacity No. Compartments �? PKG. TREATMENT PLT. ❑ Method of Disposal Distancil to nearest: Well Foundation Property Line h LEACHING LINE 1-1 No. & Length of-lines Total length/size 1 FILTER BED ❑ . Disianc f to nearest: -.Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number f k � SUMPS El Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS_ ❑ 4 w li 1 hereby certify that.] have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and �1 rules and regulations of the San Joaquin Local Health.District. I� Home owner or licensed agents 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 ows.of-C.alifomia."Contractor's hiring or sub-contraetifig signature x kcertifies 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." ul r �. T call I s c late drawing on re rse side. i] V_r - !i Signed Title:` �� f/1- 1 Date: } II _-.. . FOR DEPARTMENT USE ONLY I` Appli n Acc ted by 4 ?' "* Date Area '-Pit or Grout Inspection by Date Final Inspection by f Date j 1 Additional Comments: �M li ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Appilcant- Return all copies1to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l INFOFEE AMOUNT'DUE' AMOUNT REMITTED C1C H RECEIVED BY �r DATE PERMIT"NO. I a'IEH 13-20(REV.t e 5) 0 ""� .f`)[) f r/�j f Y� EH 1428 ll l J `-�"�` 1 1�`-�✓ C y I