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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ON AVE., STOCKTOIV, CA 0 1601 E. HAZELT Telephone (209) 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Id° (Complete in Triplicate) nDistrict for a pe . This Application is hereby made to the San fCounty Ordiuin nance No.549 for sewage or INo 1862 forcwand/or elllpump and the Rules herein Health es and Regulations application of the Regulations Joaquin made In compliance with San Joalq Local Health District. iA � City Lot Size —2 .ZM Job Address ` I' —q10 �� U: Phone Address �S� Owner's Name ',n, I Phone` _ Address l'7 License No. --- phone! DESTRUCTION ❑ II NEW WELL ❑ WELL REPLACEME T ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES _��— DISPOSAL FLD. PROP. } DISTANCE TO NEAREST: SEPTIC TANK OTHER WE PITS/SUMPS FOUNDATION �� AGRICULTURE WELL ::. ECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU Dia. of Well Casing ❑ Oen Bottom 171 Manteca of Well Excavation ❑ Industrial p Type of Casing Specifications LJ Domestic/Private. El Gravel Pack (-1Type o1 Grout Seal Type of Grout t`i Public F Other f i Delta p .. . .Ia.. pprox. Depth,. I I Eastern Surface Seal Installed by I I irrigation- HIP. State Work Done — i Repair Work Do Type of Pump- Well D ction [l Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 W system Pe TYPE OF SEPTIC WORK: NEW INSTALLATION.}( REPAIRIADDITION DESTRUCTION I I availablelwthin 200 feert�ed if public sewer Is t '1 ( Installation will'serve: Residence Commercial Other_�� N Number of liding units: Number of bedrooms -- Water table depth (4� t Character of soil to a depth(of 3 feet: Capacity No. Compartments Y SEPTIC TANK ❑ .Type/Mfg �� ; � Method of Disposal PKG. TREATMENT PLT. ❑ , r �-� / Distance to nearest: Well C Foundation—l7— Property Line Total length/size LEACHING LINE ❑ No. a Length of lines Property Line I FILTER BED 171irt1 Distance to nearest: Well Foundation I 1 ' H _ Number SEEPAGEPITSr. l'I'llDepth Size Property Line SUMPS Ll i[ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ l t 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. signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not "Home owner or licensed agent's f' 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." i The m II for all equired ins cti s. Complete drawing on reverse side. .Title: Date: S FOR DEPAR ENT USE ONLY Date Area 1 Area 11 0 Application Accepted by i Pit or Gr6ut Inspection by bate' Final Inspection by Date Additional Comments: I ❑ Stk 466-6781 L] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i 0 CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO + EH 13-24(REV.,)/n 51 EH 14-2a it