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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (Complete in Triplicate) Application is he€eby 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 .��/ ¢^ f"h PY ��/ +' City.. - ` .Lot Size PM C hone ° Aress Owner's Name P l.. `' .. ,""�` Phone k_...Contraclor.__ Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F1 " "`® SYSTEM REPAIR ❑' "OTHER E] DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION + AGRICULTURE OTHER WELL PITSISUMPS _ INTENDED USE rTYPE OF WELL BLEM AR CONSTRUCTION SPECIFICATIONS �^ Industrial- "R Open Bottom' -❑ Ma Dia- of Well Excavation Dia. of(Nell Casing ❑ Domestic/Private lD Grave! Pack ❑ acy Type of Casing Specifications ' r i ❑ Public - 111 Other Cl Delta r Depth of Grout Seal Type of Grout E o w=A rox D` h ? i-I-Eastern w- - r[aca Seal Installed U d 11Irr€gation �--� ---r, --. pp w - r-_ Repair Work Done ❑ Type of Pu H P. State Work Done t F € Well Destruction ! -❑.- Well Diam er Sealing Material Itop 50'l� _ -Material Below 50'1 ^ Depth - Filler Mate f r f ' TYPE OF SEPTIC WORK: NEW,INSTALLATION f�I� REPAIRIADDITION l N I DESTRUCTIO ' INoseptrc system permitted if public sewer is u_ ..__. ._._..,.w.__._._..-_._ .. ..- .. available-Within 200leet.l s Installation will serve: Residence_ Commercial .Other __ , _„_ ��,-,,,-. . �,..••„_ _...f.... .... Number of;living units: Number of bedrooms Chbtacter'of soil td'a depth"of 3 feet:" ' "'* Watertable depth' SEP_TIC`TANK 0i TType/Mfg, �"' Capac_ity ,.._. No._Campartments _ j _ PKG. TREATMENT PLT. 0' � � � � Method of Disposal LL � M. to'nearest: Well Foundatiori'" rProperty 7 ine LE - g ACHING LINE E ❑€ No &'Len Length of lines Total length/size i ._Prop rty'Line -- FILTER BED'--"" "I CJ'`-Disfance to nearest —1-'We ll Foundation SEEPAGE PITS l I'. Depth a Size Number ' } i r " roperty"Line! ---SUMPS-- L1:-Distance'to nearest. Well � 'FoundationP DISPOSAL PONDS ❑ k I ' I hereby certify that I Have prepared this application and that the work will be done in accordance with San Joaquin county ordinarices,state laws and - - •rules and regulations•of the.San-Joaquin-Local.Health District. Home owner or licensed agent's signature certifies the following: "1 certify that the performance f the work for,wh€ch this'permit is issued, I shall not -. --employ any person in such-manner as to become subject to workman,s-compensation laws"of Califohnta 'Contractor s:hiiirig or sub contracting signature- employ i certifies the following: I certify that in the performance of the work for whEch this permit is issued, I shall employ persons subject to workman's compensa 5 o.tion•-laws-of-California _.• _.__i._ x ...; .- - r x —. The applicant' c r a1 uire inspections Complete drawing on reverse side. Signed XTitle: {� N - , Date -- d ' - a DEPARTMENT USE ONLY Applkcatl Accepted by j N _- v -Dae - Area r Pit'or Grout Inspections by �' - _ DateH rt lei al nspect€on by t Dat� Q � € L'odi-`369621 Manteca -823-7104- O Tracy,.835 6385 4 - V Additional Comments: 0. -Stk-466-6781- _-E_S- .M- - 2- 1s r_ .s . 1 Applicant- Return all copies to: Environmental Health Permit/Servlc.s 1601E Hazelton Ave., PCO: Box 200J Stk., CA 95201 FEE OL1NT(5UE AMOUNT REN1l1TED y - RECEIVED BY, jDATE PERMI AiNT NO. I INFO CK__. r.EH 13-24.IREV.}tip5} S7 EK EH 14-28