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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripkate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal{the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpurrip and the Rules and Regulations of the San JoagLin Local Health District. 19!J_=0 .a _ City, " -- Lot Size, +d�/s� PM Job Address „� phone -11L-Z Owner's Name 1 �}�� License No.a��Phone Contractor_!ALL Address NE ELL ❑ WELL REPLACEMENT Ci-rDESTRUCTION.,❑ -'-` f'jC�t/f 7YPE OF WELL/PUMP: OTHER C ----- 1 SYSTEM REPAIR ❑ PUMP INSTALLATION SEWER LINES DISPOSAL FLD.—. PROP. LINE { DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS _ !. AGRICULTURE WELL AGRICU _ FOUNDATION -- t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S - << I _ Dia. of Well Casing a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications S',41--ed Gravel Pack ❑ Tracy Type of Casing * �- ❑ Domestic/Private ' Type of Grout '. DnGt y►dN�!/ Cl Delta Depth of Grout Seal f” Public I-i Other s/ f _ `Al 31 -Approx. Depth I ! Eastern Surface Seat Installed by-- i Irrigation State Work Done — • I Repair Work Done Ci Type of Pump _ — Sealing Material (top 50'1 Well Destruction U Well Diameter i ; 1 t 50_ Filler Material (Below 5 Depth TYPE OF SEPTIC WORK: NEW INSTALI AT1bN l l REPAIR/ADDITION t DESTRUCTION I I ailabe Napwit in septic00 teet'tled d public sewer is Installation will serve: Residence,.. Commercial— Others Number of living units: . Number of bedrooms Water table depth— Character of soil to a depth of 3 feet:_ No. Compartments ❑ T e%M SEPTIC TANK YP 9 Method of Disposal _ f PKG. TREATMENT PLT. ❑ Distance to nearest: Well _� Foundation f PropertV Line _ Total-length/,sze— LEACHING LINE ❑ No. & Length of lines .�pro a f 'r FILTER BED ❑ Distance to nearest: Well__. _ Foundation_... -- P rtY Line Size SEEPAGE PITS I Depth Number Distance to nearest; Well Foundation__ Property Line SUMPS _ -._ „�„__1 ___.,�---T DISPOSAL PONDS :1 r , 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 E rules and regulations of the San`Joaquin Local Health District. 1 f rk for which this permit is issued, I shall.not ` Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wosignature employ any person in such manner as to become subject to workman's comperisation taws of California."Contractor's nsirnbject to workg or tmanlscompensa 4 certifies the following: "I certify that in the performance of the work for which this pa'mit is issued,I shall employ pe 1 } tion laws of California." The applicant must or ail r iced inspe 'ons. Complete drawing on reverse side. -. It i # t e: ° Date: - Signed _ FOR DEPARTMENT USE ONLY ��r t ^Y.rL b f Application Accepted by Date Area A-- 7 ,i — Pit or Grout Inspection _-Date C Final Inspection by Data Additional Comments: LJ Stk 466-6781 U- Lodi 369-3621 ❑ Manteca-823-7104 _ C] Tracy 835-5385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hsiolton Ave.,.P.O. Box 2009, Stk., CA 95201 ttt FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO � EH 1124(REV-i/5 SiEH 14-28 J