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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � 16 O 01 E. HAZELTON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - t (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit o. 62for y11/pump and the Rules and Regulations of the San Joaquin 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. 188&2 Local Health District. Lot Size Size PM y70.7 S /�/r _ —____—___—� city / Job Address — �� Phone Address L Owner's Name nr J (j// r License Pio.`"2 __--��Phone Conlractor �� ' Address TYPE OF WELL/PU P: DESTRUCTION ❑ _ NEW WELL ❑ WELL REPLACEMENT ❑ ` iYSTEM REPAIR 1� OTHER 11PUMP INSTALLATION ❑ SEWERLINES DISPOSAL FLD. PROP. LINE , MPS PITS/SU DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL _ FOUNDATION - , INTENDED USE TYPE OF WELL PROBAREA CONSTRUCTION SPECIF)CAT10NS Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation O Industrial Type 1 Specifications mof Casing ❑ Domestic/Private O Gravel Pack ❑Tracy t tl of Grout Seal" Type of Grout i'1 Public Cl Other it Dehepa D _ ^Approx. Depth , 1 I Eastern Surface Sea Installed by_ I I Irrigation State Work Done of Pump H.P., ,- Repair Work Dona D Type � _ —�--- Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below,501 TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION I -DESTRUCTION-111 affil avaic system lable thin 200feet.) if public sewer is V Installation will serve! Residence`� Commercial 3piher� Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: ZoQ� Water table depth Q P Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal A� PKG. TREATMENT PLT. ❑ f 1� Distance to nearest: Well Fourfdation Property Line Totallength//size LEACHING LINE LlNo. & Length of lines ,.,, . a t _.. ,pro Line FILTER BED El Distance to nearest: Well �2. Foundation tY Size '"� -• f.� Number SEEPAGE PITS t 1 Depth _ SUMPS L1 Distance to nearest: Well Foundation, s Property Line DISPOSAL PONDS ❑ ill'be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that 1 have prepared this application and that'the work w rules and regulations of the San Joaquin Local Health District. T Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the walk'#or which this permit is issued, I shall not to workman's compensation laws.of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject certifies the following:"'1 certify that in the performance of the work for which this permit is issued,I shat employ persons subject to workman's compensa- tion laws of California." 1 The applicant must call for all required inspections. Complete drawing on reve a side- Signed X4A 'A Title: Date: x r�. OR ARTM NT U E ONLY - •—.. 77- Dater:�� Q Area Application Accepted by ?� Pit or Grbut Inspection by ^' Dae .Final Inspection by DBLB�� Additional Comments: F ❑ Stk 466-6781 C3Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: EnvironmentalHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �Y a EN 1324(REV,I i a 41 ` 8 O EH 14-28