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J, r ' APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT - 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED f: v (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 a made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for welt/ um and the Rules and Regulations of the San J Local Health District. p p PPtication is r � Joaquin Job Address City Lot Size PM Owner's Name �D;�2 . . : Address � _ em�� ( �`l'7 J� 1 -Phone �" ?65' Contractor 1=--� J I Address TYPE OF WELL/PUMP: �c e No._ Phone NEW WELL Q WELL REPLACEMENT ❑ PUMP IN 7ALLATiON ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TA K OTHER ❑ SEWER LINES DISPOSAL FLD. " ! 1 FOUNDATIO AGRICULTURE WELL PROP. LINE INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WE PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca �; Dia. of Well Excavation Dia, of Well Casing , ❑ Domestic/Private, ❑ Gravel Pack E1 Tracy —Type of Casing C1 Public Other Specifications er �, deka Depth of Grout Sea! [I irrigation __gpprox'Depth ❑ astern Type of Grout Repair Work Done Q Type of Pump H,PSurface Seal e y P. ' State Work Done Well Destruction LJ Well Diameter sealing Material to 50') Depth }` iller Material I 501 4 TYPE OF SEPTIC WORK: NEW iNSTALLATiOt4,PT, P !R/ IT N ❑ DESTRUCTfON ❑ (No septic system permitted if public sewer is Installation will serve: Residence — available within 200 feet.) Commercia Ot r Number of living units: L Number of bedrooms. FVrtrev Character Of soil to a depth of 3 feet: ' SEPTIC TANKWe Type/Mfg d0]? k Water table depth � �r PKG. TREATMENT PLT. F1p '� CapacityNo. Compartments �.. • �';'� �, / Method of Disposal Distance to nearest: Well Ft�undation�� ° Property P P rtY Line LEACHING LINE No. & Length of lines Total length/size a a i ❑ Distance to nearest: Well tL FILTER BED c2�c Founrtion 30r Property Line�� t SEEPAGE PiTS ..8' Depth / Size Jt , _ Number 2 SUMPS ❑ Distance to nearest:-r' Well "�-- DISPOSAL PONDS El Property Line soared this application and that the work will 'ccordance with San Joaquin county ordinances, state laws, and I hereby certify that I have pr rules and regulations of the San-Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the perfprmance of the work for which this employ any person in such manner as to become subject to workman's compensation laws California."Contractor's hiring or sub-cont actngrmit is issued, lsignaltnot urre certifies the following:"I certify that in the performance of the work for which this permit is i ued,I shall employ tion laws of California." p y persons subject to workman's compensa- tion applicant mus call for all required inspections.-Complete drawing on reverse side.;'', 4, Signed _ 2 -24- Title: Date: O FOR DEPARTMENT USE ONLY Application Accepted by Date 12 Area Pit or Grout Inspectio y Date 1 s Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B x 2009, Stk., CA 95201 w ` FEE UE AMOUNT'REMITTED r INFO AMOUNT DH - RECEIVED 13Y DATEl PEMITI.N]OEH 13-241REV,tea 5) aiC EH 1428 � � � �