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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTO C8D }} Telephone (209) 466-6781 JV 11 7f PERMIT EXPIRES 9 YEAR FROM DATE I !A q1 J (Complete in Triplicate) Application is beteby made to the San Joaquin Local Health District for a permit to construct an oi'AC t an.,tication is made in compliance with San Joaquin County Ordina ce No.549 for sewage or No. 1862 for well/I u the Rules and Repuotions of the San Joaquin Local Health District. 1111'1' TTttfrf� V q 7 g 1 Job Address City Lot Size PM 470 Owner's Name ` A ress sE oc hone lZo Ld Contractor_ _ dress 1�9� License No./ fwd/�_Phone Z TYPE OF WELL/PUMP: r NEW WELL ❑ WFLL REPLA�"Et4T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPJ�IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWS LINES _ DISPOSAL FLO, PROP. LINE FOUNDATION _ AGRIC LTUR ELL OTHER WELL PITS/SUMPS (— INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante r'Dia. of Well Excavation. Dia, of Well CAsing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing 'Specifications 7 Public F1 Other ulta 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 F: ._ _ State Work Done Well Destruction ❑ Well Diameter Sat'ing Material (top FJ') Depth F Iter Material (BeJOW 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR/AOOITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg ��[.A&fD Capacity 0 No. Compartments PKG. TREATMENT PLT. ❑ l Method of Di osal _ Distance to nearest: Well d oundation__,skh Property Line 1 } — -- LEACHING LINE 0 No. & Length of lines �J i9tlength/size FILTER RED EJDistance to nearest: Well oundation _ Property Line GE PITS I I Depth Size ber SUMPS 0 Distance to nearest: Well oundation �� Property Line AL PONDS ❑ 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 District. -,I 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contracto's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for quired ' spections. Complete drawing On'reverse Side. Signed X Title: - d- 'LA4 _ Date: FOR DEPARTMENT USE ONLY Application Accepted by -' .� Date 3 A Pit w Grout inspection by Date Final Inspection by _ D.by QAdditional Comments: nA., - ❑ Stk 466-6781 ❑ Lodi 369-3621 10 Manteca 823-71 [-] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P_0. BoxYEE $,PQr�D'1o� // INFO AMOUNT DUE AMOU REMITTED CK RECEIVED BY DA EH 14-26