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APPLICATION FOR PERMIT S.1N JOAQUIN LOCAL HEALTH DISTRICT II 1 ")1 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 3' PERMIT EXPIRES TYEAR FROM DATE ISSUED r (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. i� Lot Size PM Job Address # Owner's Namei�Kdress Phone fk R 5 f ss- �d`�� License No :—PhonL r� � kContracta _ .TYPE OF WELL/PUMP: MEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LlSYSTEM REPAIR ❑ OTHER 17 j `DISTANCE TO NEAREST:"SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ❑.Manteca Dia. of Well Excavation. Dia. of Well Casing �XJ ,p Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` FI Public f 7 Other ❑ Delta Depth of Grout Seal Type of Grout f Q I I Irrigation —.-Approx. Depth 4 I Eastern Surface Seal Installed by - °Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C] Wel! Diameter Sealing Material [top 501. Depth It Filler Material (Below 501 LZ «TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1_1 DESTRUCTION l 1 (No septic system permitted if public sewer is w available within 200 feet.) Installation will serve:' Residence Commercial_ Other p Number of living units: —1-- Number of bedroo { Character of soil to a depth of 3 feet: Water table depth rpm" a `ASEPTIC TANK Type/Mfg 4 Capacity No. Compartments T + Method of Disposal PKG. TREATMENT PLT. ❑ Distance to near est:1 1we Foundation Property Line { ' LEACHING LINE ❑ No. & Length of lines' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS I 1 Depth , —Size Number SUMPS a ❑ Distance tnearest: Well Foundation Property Line DISPOSAL PONDS' ❑ 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 ruies and regulations of the San Joaquin Local Health District. t 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:"Contractors 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 applican us call for a4 ctions. Complete drawing on �erse side. Signed X _ 'Title. itle Date: p AAENT.USE ONLY kt J Application Accepted by ' ��- Date ��`_ ArQa—�—` Pit or Grout Inspection by date Final Inspection b, �_ Date r Additional Comments: Y ❑ Stk 466-6781 ❑ Lodi 369-3621" '"❑ N1a e a 823=7184 "'"�"❑"T"racy 835=6385" T Applicant - Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NF MOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. ♦ EH 7324 I REv.i/a 51 +✓ 0-D ' EH 11-2$ 164f r