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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephorle 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED " (Complete in Triplicate) hcation 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 r App 'made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District PM Job Addr City" r Lot Size n Phone w F�� S�60to Address Owner s Name a Y 3 f,., �E.P-�' Address A "t fro " Icense No� ��Phone ti ConEraclar.. .TYPE OF WELOPUMP: NEW WELL ❑ WELL`R1:PLACEMENT ❑ DESTRUCTION Ll t "'""PUMP INSTAL-L:ATION"Ca'""`�* " SYSTEM REPAIR-p - ;w OTHER LI- ,_.•�,, " " "��_ ��.� ~•-�._m•"""�/ I D1SfOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION," AGRICULTURE WELL OTHER WELL PITSISUMP5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ OeBottom ❑"Manteca Dia. of Well Excavation Dia. of Well Casing IJ v: Industrial. pn Specifications ;4 i 1 ` aQ Domestic I Private ❑ Graval.Pack ❑ Tracy Type of Casing _ Type of Grout - FI Other Cl Delta Depth of Grout Seal 1-1 Public + ` i I Irri anon ' Appro .-Depth—I i Eastern _Surface..5ea!:installed by + State Work Done I Repair Work'Done ❑!r: Type of Pump H.P. +. Well Destruction ` ❑ Weli-Diameter Sealing Material (top 501 N!`Depth Filler Material (Below 50'i TYPE OF SEPTIC WORK:' NEW INSTALLATION I REPAIR/ADDITION i l DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.I installation!will serve: Residence '! Commercial Other,' Number of living units: mber-of-bedrooms - . _ Water table depth Character of'soil io a depth o, fee t: •j . 0�. ' SEPTIC TANK I�ype/Mfg - opacity LIQ No. Cdrrlpartments, PKG. TREATMENT PLT. ❑ fr Method:of Disposal Distance to hearesV We11 Founda on' >�— Property Line" t Lt r r LEACHING LINE No. 8r Length of lines i s �"- Total length/size FILTER BED ❑ Distance to nearest:" Well Foundafon� Property Liner' {tJ SEEPAGE PITS l 1 Depth ��---to'--size NurVer i 1" Well to nearest- Foundation Property Line SUMPS r ' ua DISPOSAL PONDS ❑ I" I•hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county'"or`dinances,°sta Ae 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 workman's compensation laws of California." Contractor's hiring or subcontracting signature k ceftifies the following: "I certify that tri the performance,of the work_for which this permit is issued, I shall employ persons sub fecTto:workman's compensa- } tion'laws of California." i a TFigapplicant myust�call ffor all req uir ins coons. Complete drawingon reverse side. 1 Imo+' _ Title:M Sp /C-9 Date: f I I Signe;' X —" 4 it f DEPARTMENT USE ONLY r Y > Date Area Application Accepted by Date Final Inspection by Date Pit or Groui . 4:'Inspection by Additional Comments: : ❑ Stk 46&6781 ❑ Lodi 369-3621" ❑ Manteca 823 7104 ' '-�' Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services;1f301 E:;Hazehon Ave., P.O. Box 2009, StR., CA 95201 v. ,.-CK- ...� Y FEE-- AMOUNT DCIE" '" "AMOl7Ni`xREIVIITTED CASH RECEIIJ�6-BY^ 4� RDA E. PERM17 N0. INFO, I LI �a -�3 T EH 13.24(REV 1U R5) EH 14 26 t ^ 3e-