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APPLICATION FOR PERMIT 3 SAN JOAQUIN LOCAL HEALTH DISTRICT ' V. � w P 1601 E. HAZE I ON AVE., STOCKTON, CA } Telephone (209) 466-6781 -� I PERMIT EXPIRES 11,YEAR FROM DATE ISSUED (Complete in Triplicates 1~4.-ALFH Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the w&k%rein escribedf 7h1s 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. E Job Address S, City �� f Lot Size PM Owner's Name ddress 5.47-y7,— __— Phone 41a -3« J - Contractor F4o,e,o C—_ Lcl".D Address License No. Y7L Phoned 7 TYPE OF WELL/PUMP: NEW WELL ❑ . . WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ `'• `- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE j _ FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack .0.racy Type of Casing Specifications FI Public n Other r rp. ,M Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth, I&Eastern Surface Seal Installed by I j Repair Work Done ❑ Type of Pump H.P, - -•.State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I -5epriC—system permiit6tt-if-v lic sewer is LA y_ available within 200 feet) Installation will serve: Residence_ Xommercial,_7z Number of living units: Number of bedrooms Character of soil to a depth.of 3 feet: _ ��✓ ,SF Ater table depth SEPTIC TANK ; Type/Mfg ae; lb 9�-L--'r CapacitNo. Compartments � f n 1 1 ' V PKG. TREATMENT PLT. ❑ v '� # f a ' v� r; , Method of Disposal Distance to nearest: Well 2/ey Foundation I'S I Property Line LEACHING LINE r l No. & Length of litres '��•� r 'Total'leii_t0T/site IC'C/' F f� FILTER BED 11 Distance to nearest: Well �Ad._ Foundation ti-�/f/ Property Line i SEEPAGE PITS 1 i I 1 Depth Size Number i SUMPS r ❑ Distance to nearest: Well h Foundation Property Line - DISPOSAL PONDS C1 _ "r- - I hereby certify that I have prepardd'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. i w ; Home owner of ficensed agent's signature certifies the following: 1 certify that in the perffrm ance'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." I% The applicant must call for all required inspections. Complete drawing on reverse side. Signed X ,Zoe Title: Date: Z7 p� FOR DEPARTMENT USE ONLY Application Accepted by Date –p- Area f Pit or Grout inspection by Date Final Inspection by I Date Additional Comments: Aga ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ID racy 836-6385 Applicant - Refum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 11 , �{ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED f3Y OATS PERMIT NO. f INFO CASH + EH 13-24{REV.I/n ti) V'7 '9fo 2,5 EH 14.213 kA_42�L YJ C/