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. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601''£:-�AZELI OOAVE., STOCKTON, CA 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. l) S.3 O [✓ City •��t`�I��bt�$ize PM Job Address + �} ne Owner's Name a t r� .-, r �(� �pv Contractor L ddress Z~ License No. Z Phone Ct �JYPE OF WELL/PUMP: NEW WELL FT WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIRR❑ OTHE "1- � ER LINES f Q G1� DISPOSAL FLD. 0 �nUP- LINE fit/ 1 s 1 DISTANCE TO NEAREST: SEPTIC TANK IFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I _ 11 IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑��Open Bottom ❑ Manteca Dia. of Well Excavationto V G Specifications ❑ D estrc/Private lSCiravel Pack ❑0�/TTracy Type of Casing i ❑ Other 216elta Depth of Grout Seal Type of rout ubllc � ElIrrigation r -2-approx. Depth D stem Surface Seal Installed by VAX.. RepairIWork Done ❑ Type of Pump �- H:P. S State Work Done Well Destruction LlWell Diameter Sealing Material (top 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION ElDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r i Installation will serve: Residence, Commercial_ Other Number of living units: S Number of bedrooms_ —Chatacter of sail to a depth of 3 feet: _ f Water.�table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of pisposal� - '� t I Distance to nearest: Well ' Foundation Property Line %"' LEACHING LINE ❑ No. & Length of lines `r Total length/size FILTER BED ElDistance to nearest: Well '? Foundatidn t� = / Prop rty LiweyJ — — fSize 1! 1r a` rNumber SEEPAGE PITS ❑ Dep Pro Line � `W SUMPS ❑ Distance to nearest: Well - Foundation Property DISPOSAL PONDS C DISPOSAL certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an� Y �- rules and regulations of the San Joaquin Local Health District.; si' ' I Nome owner ' nse nt's signature certifies the following: "I certify that in the performance of the _work for whk h this permit is issued. I Mall not employ an arson In such nner as to become subject t orkrtla 's compensation laws of California."Contractors hiring or sub-cont6din9 signature certifres a following: "I c that In the performs ce t work or which this permit is issued,1st1a11 employ persons subject to workmaj s compensa- tion 1a of Califo nis." Thea .pllcant u r all req di awing0,11 a Signed Title: Date: i DEPARTMENT USE ONLY i Application ccepted r�� Pit o ;Grout I ct y rr Date 1- .3 6 Area f ate JI Mspection by Date 3 /Q� ` Additional Comments: Ik ❑ Stk 486-fi781 C Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-M Appfirant- Return all copies to: Environmental Health Pemrt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE CK RECEIVED DATE PERMIT''NO. INFO AMOUNT DUE AMOUNT REMITTED CASH I-, 6 4J1 ♦ EH 13241REV,1%e5J � O EN 14.28