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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 1 YEAR FROM DATE ISSUED /Complete in Triplicate) Application is heieby 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 Lot Size PM Owner's Nameyf-11M Address 14=4� Phone ��77 --ply- � � �° License Nolo` Phone Contracto?�— a� - �`�� Address � TYPE OF WELL/PUMP: NEW WELL` ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ - -DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WEL1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,. i CJ Industrial 13Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing I4 *omestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing Specifications + i-1 Public f_� Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by RepairWork Done Type of Pump �° H.P. �� State Work-Dane -_�S -r •'-� Well Destruction ❑ Well Diameter Sealing Material [top 501- gyp Depth Filler Material IRelow 50') -- -TVPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: atertable depth� SEPTIC TANK ❑ Type/Mfg Capacity s': 119 01 Gor�rt a PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation � rope�ty Line�� LEACHING LINE ❑ No. & Length of lines _ Total-length/*ize IrAl T= ENV",C ,�� _,.•:; res _.. FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number �" 4 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 rules and regulations of the San Joaquin Local Health Di§trict. 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, 1 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 applicant st call for quired inspections. Complete drawing on reverse side. CM Signed XIH3 -67 _ Title: Date: EPARTMENT USE ONLY Application Accepted by Date_111_00�r Area Pit or Grout Inspection by Date Final Inspection by to Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e I FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY DATE PERMIT NO. I INFO CASH +.EH 13-24 iM-i/H 5) b �I --a EH 14-28 I