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V'" APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA �- 2 4^ N 7RO4 y�6 Telephone (209) 466-6781 Ff ' - It PERMIT EXPIRES 1 YEAR FROM DATE•ISSUED TjsERV,CfS�47, (Complete in Triplicate) 4 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 f Local Health District. Jab Addressen "oii� � ' ' City Lot Size PM Owner's Namer ® '7 � II .=L_ �Phone � Contractor . Address License No. W Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT A DESTRUCTION ❑ PUMP INSTALLATION ❑f SYSTEM REPAIR ❑ THFR ❑ t DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l� ❑ ndustrial ❑ Gpen Bottom 1-1MantecaDia. of Well Excavati Dia. of Well Casing Domestic/Private ravel Pack ❑ Tracy Type of Casing 1e Specifications ❑ Public ❑ Other Delta Depth of Grout Seal 4r7 Type of Grout ,X0 ❑ Irrigation 10-ff.Approx.'Depth ❑ Eastern Surface Seal Installed by �`- _- ' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is } available within 200 feet.] fi Installation will serve: Residence._.._ Commercial— Other Number of living units: 'Number of bedrooms pq Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 r - d SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ 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 1 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 compere tion laws of Calif The applica must call for require ns ctions. Complete drawing on reve side. Signed Itle: .� 1(� Date:. _ 1 FOR DEPARTMENT USE ONLY Application Accepted by 1 Data_ �- ��}- Area 112- Pit � Pit or rou nspection by� Date inal Inspection by J > � „�7 Date f •` l� I Additional Comments: II d ❑ Stk 466-6781 ❑.Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a, i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., 0.0. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. + EH11241REV.i/a51 EH 14.28 � Oc::J