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F�� r< APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE.._STOGKTON, CA Telephone (209) 466-6781 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. .� Cit 7 Lot Size 0G�G _ PM Job Address , Owner's Name 1 �-r^Y Andress �C� Phone D g��3 Contractor aAddress License No. .. { TYPE OF WELL/PUMP: i W WELL' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ! SYSTEM REPAIR ❑ OTHER ❑ �'] DISTANCE TO NEAREST: SEPTIC TANK 9l,+)^1 r SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION �L-.._ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , 175 ❑ Industrial :Open Bottom ❑ Manteca-__� ,bia-of-Well Excavat Dia. of Well Casing _C� `Domestic/Private E3 Gravel ❑ 'Tracy Type of Casing Secifications` .� J P .r fl public Ll Other' ❑ Delta "� Depth of Grout Seal Type-of, rout . I I Irrigation �_Approx. Depth 1 Eastern ^Surface SeaI installed by j �' k Repair Work Done L3 Type of Pump 1 H.P. l - State Work Done Well Destruction ❑ Well DiameterSeaeng-Ma�eGial itop 501 Depth - ..'Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other _ Number of living units: rrN mbe�of bedrooms Character of soil to a depthof3 feet: 4. Water table depth SEPTIC TANK ❑ Type/Mfg �T x Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No'-& Length of lines Total length/size FILTER BED ❑ Distance to nearest: .. Well Foundation Property Line SEEPAGE PITS 1-1 Depth Size Number,/ c SUMPS Ll Distance to nearest: Well Foundation Property Line' DISPOSAL PONDS ❑ tY 1 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: "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 must call for all required inspections. Complete drawing on reverse side. f r Signed X i Title: �-�- �'—�.a Date: q OR DEPARTMENT USE ONLY : Application Accepted by Date V" � Area Pit or Grout Inspection by fData_�_,C�y' Final Inspection by p e l Zz�r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 _ ❑ Trky 835-5385 'r Applicant—Return all-copies to:-Environmental Health Permit/Services 1601 E'. Haielton AVU:7P.O.'Bdit 2009;`Stk:; CA-95201 ' FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. INFO t-EH 53-24IREV.ilms1 V� EH 14.28 i-,