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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT2- 1601 E. HAZELTON AVE., STOCKTON, CAS'=(� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .dtion 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 ,ue 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 ,ocal Health District. 9s2g0 /�� / 9 l OQ" City Lot Size 6 ert*E PM Job Address ` � , S Phone Owner's Name //�� /�(. �Ad� ress el# `1 Cr IC V !v License No.,�r77 7 81 Pho Contractor Address TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT El DESTRUCTION ❑ O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER $ ZN�"Cc�1bs+ �(!�� _ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION 7�0 AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 3 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing k'SS Specifications ❑ Domestic/Private ❑ Gravel Pack .❑ Tracy It'LC I"1 Public 1-1 Other ❑ Delta Depth of Grout Seal I we Type of Grout I I Irrigation ,3o�Approx. Depth I I Eastern Surface Seal Installed S l k Done �' Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION IN(No septic system rented if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg Capacity No. CompartmentsEEEE4 Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: 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 rules and regulations of the San Joaquin Local Health District. cert that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I pensation laws of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's com 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 applicant must call for all required inspections. Comp a drawing on reverse s• Date: Signed X FOR DEPARTMENT USE ONLY Date C. ()Area Application Accepted by p ��e/&_' Date Final Inspection by��`� Pit Gro Inspection by –l- I' (71V)739 -8L-;?2 ,/` ar �rvt Additional Comments: �rttlKt ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s��yVwt FEE AMOUNT DUE AMOUNT REMITTED CK 8 SH RECEIVED BY DATE PERMIT NO. INFO //�/ / 9 fll� EH 13-24(REV.i i n s1 �oe 11✓ /7( L) �� l �� EH 14-29