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APPLICATION FOR PERMIT L HEA SAN JOAQUIN LOCA i LTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466`6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUcJ2 �y ✓ ! (Complete in Triplii'ate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ation is insta a work herein described. This San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the } Local Health District. ! Lot Size PM Job Address City K Address Phone Owner's Name s ,_ Contractor U(rf 1f_ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 1-1WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -� �--•-- -� .r -- -.- _ --.- - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrials -;❑ 0pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing —` -i. ' °'"R"" ` ; Type of CasingSpecifications k ❑ Domestic/Private ❑ Gravel Pack © Tracyn Type of Grout FI Public t Ll Other ❑ Delta Depth of Grout Seal I I Irrigation, _.-Appfox. Depth i i Eastern Surface Seal Installed by r H.P. . State Work Done_ �+ Repair Work Done ❑ Type of PumpF Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth f T=iller Material (Below 50'1 c� TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIRIADDITION l I DESTRUCTION (No septic system permitted if public sewer is 1. available within 200 feet-1 { , E Installation will serve: Residence Commercial_ Other P f^�� Number of living units: Number of bedrooms r f Character of soil to a depth of 3 feet: Water table depth \ SEPTIC TANK. C] Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. C7 Il Method of Disposal _ Distance to nearest:""` 'Well' ""�' Foufidation Property Line b LEACHING LINE ElNo. & 'Length of lines ? Total length/size FILTER BEq ❑ Distance to nearest: Well .. ,_— Foundation Property Line tA y SEEPAGE PITS l I Depth Size Number SUMPS L] Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS I �1 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 Di§trict. F (� Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature �� 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." ___J 1� . The applicant must call for all required inspections. omplete drawing on reverse s ide. _� d - P C> ! Q(rf�i Date: Signed X Title: a- FOR DEPARTMENT USE ONLY Application Accepted'by Date Area �j7 fs 8 Pit or Grout Inspection _ Date Final Inspeection by� - Oate Additional Comments: — - a 4 i__lej k_ � ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HIS zelton Ave., P.O. Box 2009, Stk., CA 95201 ;d FEE AMOUNT DUE AMOUNT REMITTED CASH E; RECEIVED BY DATE PERMIT'NO. INFO 00 , +.EH 13-24MEV.I/n5) 4i X4:1) EH 14-2e �. El.