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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES T 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 scribed, This application made H 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. �• � � �-: /y g � v Job Address _MW ��FIJ �.S ��, ' II `� City r Lot Size [ PM Owner's Name 1C0 t ., �I" 4 Address O/'Z. .x�r `N � `�� 1 Phone O i Contractor's Narile «rLicerisehN6. TYPE OF WELL/PUMP , - ` NEWWELL : , n.. -Phone WELL REPLACEMENT, DESTRUCTION❑ r ..'..'- ----;W—PUMP-INSTAELATEON ❑-n Sy RERAfR- OiSTANCE'TO NEAREST: SEPTIC TANK SEWER Ll S C - - OTHER••fp;- ,�.�__3 t. DISPOSAL FLD. 's - PROP._LINEIZ30 FOUNDATION _^� AGRICULTURE WELL � '` _ — PITS/SUMPS i OTHER WELL - I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S C� ❑'Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia.-of Well Casin Domestic/Private ❑ Gravel'Pack '❑ Tracy Type of Casing 4 g 0,Public Cl Othef SP ieations 71/4 g -- ❑ Delta Depth of Grout Seal _� Type of Grodt 47 ❑1Irri Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by S �. Repair Work Done Cl Type 4-Pump H,P. s State Work Done Well Destruction E3We11'Diameter Sealing Material (top 50') " Depthl Filler Material (Below 50') :; TYPE OF SEPTIC WORK: NE INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTION ❑ IN septic system permitted if public sewer is # available within 200 feet.) Installation will serve: Residence_ Commercial! Other Number of living units: J�Number of bedrooms Character'of soil to a depth of'3 fait: SEPTIC TANK ! i — r Water table depth ❑ fie/Mfg f Capacity No. Compartments ` PKG.,TREATMENT PLT. ❑ Method of Disposal 11 _ . . Distance to nearest: Weil Foundation Property Line r � r. 1�-;> LEACHING=L"lNE � �❑� No.,& Length of lines Total length/size FILTER"BED��-- -- - ' ©"-[}istance_to,nearest: Well-^----•' r � ; Foundation Property Line ri SEEPAGE PITS El Depth Size SUMPS s .- Number ❑ DisYBnce to nearest.- DISPOSAL PONDS ❑ Foundation Property Line r" 11 I 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 4 rulesjand regulations of the San Joaquin Local Health District. ' Hdme ownar 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 became subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I certify that tion in the performance of the work for which this permit is issued,I shall employ laws of California." �I`° ,- Persons subject to workman's compensa- P The applicant mu .c 11-regvired•i spection omptete drawing on revers side. ► Signed SFORTitle: Date: IJ 95- FOR DEPAR MENT USE ONLY Applyiycation Accepted by Date / Area _ F Pit or Groutlnspection by Date :Final ec Insption by D ate Add tional Comments: .- - w ❑ S#k 468;6781 Lodi 369-3621 ❑ Manteca 823-7104 ,❑,,Trac 635-6385 - 1i y Applicant- Return all copi to: Environmental Health Permit/Services 1001'E. Hizelton Ave., P.O. Box 2009, Stk., CA 95201 - CK INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ;E . ff 1 + EH 13-24 TREY.101631 �„j 4. {" � EH 1426 �Y. ass-1367 � }