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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (20.9) 466-6731 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address _ City v , Lot Size__—^___— PM 1 Y Owner's Name —.---- Address -------- Phone .---_----___--- i p- r ` Contractor��l_ �R Address——21`� _ License No.z4a=I_Phone TYPE OF WELL/PLIMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION I I 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [I DISTANCE TO NEARFST: SEPTIC T_NK SEWER LINES --- DISPOSAL FLD.,—.___ PROP. LINE FOUNDATION AGRICULTIIRr_WELL_-_,__,. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL _ PROP LEM AREA :nNSTRUCTION SPECIFICATIONS 1 L! Industrial 1.1 Open Bottom L.i Manteca _.:. of H to Excavation Oia. of Well Caairhq ❑ Domestic/Private n Gravel Pack (A Tracy rvpF,..Casim `_ Speciftatiom ❑ Public (.I Other [-I Delta JeI.n of Grout Seal -- Type of Grout ❑Irrigation —Approx. Depth J L;tem F iAacei Inst&&,.;by Repak Work Done (1 Type of Pump .i P. _ State Work Done t Weft Destruction D Wen Diameter -- S1•, tuial(top 501 Depth Fill"Material(Below 609 TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION Ll DESTRUCTION Ll (No sept6 system permitted R public sewer is within 200 feet.) Installation will sen-e: Res � Commercial_ Other 2 Number of living unite: Number of bedrooms Characte, of soil to a depth of 3 feet: 1AQWater table depth SEPTIC TANK 11 Type/Mfg __C_ACL_"C Capacity 1 :)L Q No.cwnpwtments — PKG. TREATMENT PLT.Cl .� �� Method of 19 Distance to nearest: Wes? fo ' undation�— Property Lina 1 � LEACHING LINE I 8 Length of lines r —Total length/size FILTER BED Ll Distance to neerest: Wall Foundation Property Lire t« y SEEPAGE PITS H,—Z;ptn _Sim Nup+ber h SUMPS LI Uistanee to nearest: Wen_ Foundation 62n Property Line DISPOSAL PONDS I] 1 hereby certify that I have orepared this application and that the work will be dorm In accordance with San Joaquin county ordinances,state laws•uxl rules and rVulatiora of the San Joaquin Local HeMth District. Home owner or licensed agent's signature certifies the following:"I certhy that In the pufornwnce of the work for which this pxrrit is based,I shah not '. Wmpby any person M such manner as to becoms subject to workman's compensation hos of California."Contractor's hiring or sub-ry nti acting sfgrmt— tlhe toMovvirq:"I csr'Ih that in the performance of the work for which this pump m Is Issued,I shah employ persons subjoin to wa.....,.. :-trlpenes- t on f Canforn4i g DDIIu cast aR for NI epu edin et Co drewkq on pvuM dd swn.d �.� -- -- � - Dan: - � -- - FOR DEPARTMM USE ONLY C)_ 2 Application Accepted by �— rim ArM —G-.� Pk or Grout Inslectb Date Foal Inspection by Dete Additional Comments: �l L••r' I ro L L Stk 106.6781 ❑ Lodl 309.3021 ❑ Manteca 823.7104 ❑Tracy 8360366 AppNeuht- Return all copies to: Environmental Hos:th Permit/Servfose 1001 E.Haislton Ave., P.O.Box 2089,Stk.,to 96201 FEE AMOUNT DUE AMOUNT REMITTCD CASH RECEMO BY INFO DATE PERMITNlO. . EN1111 1111Ev.• O �S EN 14-M t.dj1WL•'ir.�ta7M1tu��;$'-•`LF.:;.,,^,•;iii.aM•,rwis�.q�..