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I V I� 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 hereby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I fl(d 5 l A- City_5 Lot Size PM Owner's Name �`r " '' Address �If_/iC4 Phone 'Contractor�� fATO S Address `7 t0 J1 L1N ' License No. SqPhone TYPE OF WELL/PUMP: li NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR d OTHER ❑ DISTA TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE 0 PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial C] Open Bottom ❑ Dia. of Well Excavation Dia. of Well Casing �• ❑ Domestic/Private Cl Gravel Pack ❑ Tracy of Casing Specifications A-60 M Public F1 Other L� Delta Depth of eai Type of Grout C� I I Irrigation _-Approx. Depth I i Eastern Surface Seal Installed +yr Repair Work Done ❑ Type of Pump H.P: State Work. Well Destruction ❑ Well Diameter �.Sealing Material (top 50'1 Depth Filler Material {Below 501 ++ TYPE OF SEPTIC WORK: NEW INSTALLATION (-I REPAIR/ADDITION l I DESTRUCTION. Wo septic system-permitted if public sewer is available within.200 feet.) Installation will serve: Residence_ Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: # Water,table depth f t SEPTIC TANK ❑ Type/Mfg t CapacityD No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No..& Length of lines Total length/ske j' > 1 FILTER BED 171Distance to nearest: Well F ndation— - __ Props'erty Line f SEEPAGE PITS I I Depth Size 0kANumber- SUMPS ❑ Distance to nearest: Well Foundation -J i Property Line a DISPOSAL PONDS ❑ s ' I hereby certify that I have prepared this application and that the work will Le`done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1%4 T-- t Nome owner 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 employan I P - i y person in such manner as to become subject to workman's com ensation laws of Cali#orroia ''Cont�acio�s hiring or sub-contracting signature i 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, f tion laws of California." .The applicant st all for II required ins ctions. Complete drawing on reverse side. Ik Signed e Title. Data: n FORD ARTiNENT SE ONLY Application Accepted by Date 7 U Area Pit or Grout Inspection by Date Final Inspection by ` Date �5 ' Ad_ditiorOtommentsi 3a � ❑ Stk `488 878a `;0 Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 E Applicant- Return all1.copies.toi,Environmental Health Permit/Services 1601 E. Hazelton Ave.,P:O. Box 2009, Stk., CA 95201 0', FEE INFO AMOUNT SUE AMOUNT REMITTED A RECEIVED BY DATE PERMITNO. £ t EHt3-24 IREV. EH 14-26 V � r