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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTPANr r 1601 E. HAZELTON AVE., STOCKTON, CA �6 /a f 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 District. /� L4__ �] Job Address f 0o City � P�-Lot Size + �� t PM Owner's Namq PMA Address IsWOE, Phone -7I, 35 ContractI Address ►, d 7� / License NG 2a 7�& Phone3k S10� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER EINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pack Cl Tracy Type of Casing Specifications M Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION i I (No septic system permitted if public sewer is Q available within 200 feet.) Q Installation will serve: ft idence Commercial Other ' Number of living units: Number of e I ao Chatacter of soil to a depth of 3 feet: Water table depth l SEPTIC TANK Typ16/Mfg L Capacity_ Lccr _ No. Compartments PKG. TREATMENT PLT. ❑ ' .a / Method of Disposal Distance to nearest: Well Foundaiion R) Property Lin _ LEACHING LINE No. & Length of lines ex ] Total length/size X FILTER BED ❑ Distance to nearest: -.Well �� '-'Foundation �� Property Line 150 f t R SEEPAGE PITS >C Depth 5 _.._ 'Size f.� Number SUMPS Cl Distance to nearest: Welll 1 Q! Foundation Property Line _._.-_ DISPOSAL PONDS ❑ . I hereby certify that I have prepared this application and that the work will be dine in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 wofkman's compensation Maws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thiermit is issued,,l shall employ persons subject to workman's compensa- tion laws of California." The applicant m call for all ire inspections. Complete drawing on revs se i e. Signed X Title: Date: 1 FOR DEPARTMENT USE ONLY f> Application-Accepted by __ -Date Ay © Area Pit or Grout Inspection by I3 . fes�^�'''" 1r4 d pFinal Inspection by ga_c l.�•G• Date �p Additional Comments: o 0- L4_144 - - ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 V ❑ a(;y 835-6589 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT K It DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. +,EH13-24(REV.I/e 51 do it EH 14-29 70 di, ZQ