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APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT ,�J 1601 E. HAZELTON ON AVE., STOCKTON, CA LL O Telephone (209) 466-6781 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 Dis�yJ�� '] r^ Job Address City Size PM Owner's Name O Address P-D. �� Phory � ,Q pp• /� Contractor ress —o� t �� License No. `�- hone0 ZLIJ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION L1PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OT ER WELL (4) _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT NS . El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing{Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public n Other fl Delta Depth of Grout Seal jul,&I- I I Irrigation A pe of Groin pprox. Dept_h 1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P qq State Work Done _ Well Destruction ❑ Well Diameter o�� 21 a rng Maienal (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RLN IR/ADDITION I I DEST CTION I 1 o septic system permitted if public sewer is Installation will serve: Residence_ Commercialer available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ T Water table depth p ype/Mfg Capacity �1 PKG. TREATMENT PLT, El No. Compartments 1�n Method of Disposal Distance to nearest: Well Fo ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: W Foundati Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to neares Well Foundation DISPOSAL PONDS ❑ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance San Joaquin county ordinances, state laws, anq rules and regulations of the San Joaquin Local Health Dl�trict. nce w 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 become 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed r I Title: -0A.A-M 0 I) Date: It,— k r-1 6- OR DEPARTMENT USE ONLY Application Accepted by Date 'os Area Pit or rout Inspection by Date Fi— 11nal Inspection by� �� Date I � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED K INF CAaH— RECEIVED BYEDATEPERMIT N0. ♦ EH 13-24(REV.tints( /O ['� „�` \ �t-/ A �/✓ EH 14.26 ! J ull V \J / ' I�