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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT z 1601 E. HAZE T ON AVE., STOCKTON, CA ` 1 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. Job Address City r Lot Size PM Owner's Name `-'��' ress [` Phone 5 Can tractor- Address � License No. Phone ' f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑' F DESTRUCTION ❑-" `"_. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES D FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS �ti.k r , ❑ Industrial ❑ Open Bottom eca Dia" of Well Excavation Oia-.of_Well.-Casing ❑ Domestic/Private ❑ Grave! Pack Tr Type of Casing Specific`atio w 1'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-A ox, Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Typ " Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing M erial (top 501 Depth Filler Material (Below 501 Q) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted i1 public sewer is. I { available within 200 feet.),, . Installation will serve: esid nce X Commercial_ Other �? Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ / '' z ')r�i�,-,� „Method of Disposal Distance to nearest: Well �'�v Found'a'tion Property Line LEACHING LINE ❑ No. & Length of lines -r Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Y Property Line 25 r ' SEEPAGE PITS l I Depth Size J r Number 4 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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 applic m t call for all requir i 21 s. Comp, drawing on reverse side. f `� Signed Title: Date: L OR DEPARTMENT USE ONLY Application Accepted by ci-,� w TM Date �' Area Pit or Grout Inspection by Date Final Inspection by Date !/ i Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFO }AMOUNTyDUUE AMOUNT REMITTED CK ASH RECEIVED eY DATE PERMIT'NO. til 13-24 1 REV.1/x 57 1 OL• r(,l ZW ` Y 14-2 �� j