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APPLICATION FOR PERMIT' SAN JOAQUIN LOCAL'HEALTH DISTRICT E 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 . PERMIT EXPIRES1 YEAR FROM DATE ISSUED' (Complete in Triplicate) Y 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 Ok -.r1%rl{r arty L' � Lot Size� � �C-�'E/ PM Job Address v " - kA f i r Owner's-Name 'f 5 y Address _- Phone Contractor E�L'T3AfsR S Address �N ' Ct- icense No. �S hone "TYPE-OF'WELL-/P1�MP: "r�""""NEW-WEL'L❑"-"""'"`"'"WECL REPLACEMENT-❑T' DESTRUCTION-© -- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r-:-�INT�NDED-USE. TYPE-OF-WELL-.-. --P-ROBL-EM•AR,EA—CONSTRUCT40N-SPEGIFICATIONS---� j— ❑ lndust�rial ❑ Open Bottom ❑ Manteca?' Dia. of•Well Excavation,i .- Dia. of Well Casing i + Type of Casing Specifications ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy,, I rz r4!i ❑ Public} ❑ Other q ❑ Delta Depth of Grout Seal '? �` Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done t ° Well Destruction ❑ Well Diameter1T -------'- Sealing Material-{tap-501. -" -• -- � � !I Depth ! Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EJREPAIR/ADDITION 11i- DESTRUCTION Ll (No septic system permitted if public sewer is Vg . ."available within 200 feet.) Installation will serve: Residence tommercialt her Number of living units: -L- Number of edrooms I lb Character of soil to a depth of 3 feet: , ' Water table depth I C SEPTIC TANK NQrType/Mfg ! �� Capacity �r No. Compartments PKG. TREATMENT PLT. 17 - t Method off glsposal Distance to nearest: Well X12_ Foundation _ _Property Line j r - Total len th/size 11 LEACHING LINE �No. & Length-of lines'^!' � 9 FILTER BED 1-1Distanceto nearest: Welk Foundation Property Line yf Numer SEEPAGE PITS La/D"epth "'' t'' Siie I f( SUMPS ❑ Distance to near."est:�j }Well fi Foundation Property Line DISPOSAL PONDS. ❑, + l' I hereby certify that I have prepared"this appilcafion..and.that th'e+vbrk.will_be,done in accordance with San Joaquin county ordinances, stat laws, and rules and.regulations of the San Joaquin,Uocaf Health District'-0 i Home owner or licensed agent's signaturelcertifies the-following:1'I certify that in the performance of the work for which this permit is issued, I shall not loy any person i such manner as to become subject to workman's compensation laws of California." tractor's hiring or sub contracting signature certi the following."I certify that in the performance of the;woik for which this[permit is issued,I shall employ persons subject to workman's compensa- tion law st California. l ' I�, The applicant st call fo Il re ired i s cti plate dr wing o reverse-side.,C. . I t` Signe Title: Date: ° FOR DEPARTMENT USE ONLY G { ¢i 'r ApplicatiEon Accepted by t l Date Area O Pit or Grout Inspection by ate � �Fij,�l spection by Data _- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211: O Minteca 823-7104 ❑ Tra4�7� 835-G385 " Applicant- Return all copies to: Environmental Health:PermitlSe''Mce's 1601 E. Hazelton Ave., :P.O. Box 2009,.Stk., CA 95201 e- i t l 1 FEE �..' 6 INFO AMOUNT DUE , AMOUNT REMItI p— ,t RECEIVED BY DATE PERMIT'NO. 1 - -� 7 +EH 1324(REV.1a s f u S F ,} �b/T�5 EH 14-26 } sT 1 .: .7 i - .