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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ry Ye j (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora t s s f made in compliance with San Joaquin County Ordinance No. Permit to construct and/or instal!the work herein Local Health District 549 for sewage or No. 1862 for well/pump and the Rules and in described. e t��S�i�lon-is C Joaquin Job Address tib 1Ti. � Y City cn/1�czJ Lot Size �s~X l`f p" PM Owner's Name Address / Phone ContractorA Address 7a2 u TYPE OF WELL/PUMP N : License No. NEW WELL ❑ WELL REPLACEMENT ❑ Phone P INSTALLATION C1DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC KSYSTEM REPAIR Q OTHER ❑ SEWER LINES FOUNDATIONAGRICULTURE WEL " OSAL FLD. PROP. LINE INTENDED USE OTHER WELL�� PITS/SUMPS TYPE OF WELL BLEM AREA NSTRUCTlON SPECIFICATIONS ❑ industrial ❑ Open Bottom � - � `I ❑ Man ^-Dia.;'of`Wf?IrEzcavation ❑ Domestic/Private Cl Gravel Pack racy Dia. of Well Casing C] Public ❑ Other ❑ Delta TYPe of Casing Specifications h of Grout Seat rox. Depth !❑ Eastern Sufc elld by j Type of Grout ED al Instae Repair Work Done ype of Pump t Well DestluctiH'P' ' WState Work Done 1 ❑ Well Diameter Sealing Material (top:50') i Depth E Filler Material (Below 5C6 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑r DESTRUCTION fNo septic system permitted if public sewer is Installation will serve: Residence4Commercial4 available within 200 feet.I ! . Other Number of living units: _ Number of bediooms 'fit' 1-1v_ f CI eck. 1- Pf' Character of soil to a depth of 3 feet: f Jr SEPTIC TANK El Type/Mfg i Water table depth KG. TREATMENT PLT. ❑ Capi acity�� No. Compartments '. Method of Disposal Distance to nearest:' Well ,.' `"'. Faundailon Pro e Line- . LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size t ❑ Distance to nearest: Well Foundation~ ' i Property�Line ; —SEEPAGE PITS EJDepth i I Size Number SUMPS ❑ Distance to nearest:, Well -----DISPOSAL PONDS ❑ Foundation Property Line 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 Home owner or licensed agent's signature certifies the following: . : I g g 9= "f certify that in the performance of the work for which this permit is issued, I shall not employ an, on i uch manner as to become subject to workman's compensation.laws:of California", Contractors hiring or sub contracting signature certifie a Califo ng: I certify that in the performance the work for which this permit is issued,i shall employ persons subject to workman's com Von ws of California.' The t \ pensa applicant must c I or all require inspections mplete drawing onreprsnide. �y i Signed / •. `.Title: T1!14... .t Date: z�. i FOR DEPARTMENT'USE ONLY Application Accepted r ADate - �C4"jAreadPit or Grout Inspecti ' Date—�� Final InspectiDate Additional Comments: a "'`"` � ""�°"'""""Ch __� h ,1rC h4C Ca�t�yy� ❑ lic 466 67$1 ❑ Lodi 369-3621 ❑ Manteca " -7104 s;❑ Tracy 835-6385 --- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.`Hazekon Ave:, P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 1NF0 `, AMOUNT REMITTED CK CASH aRECEIVEDE DATE I PERMIT"No. + EH 13-24fREV,s/e5i �J �� C". Q0 11 EH 1426 7