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� APPLICATION FOR PERMIT 3F�r . SANN-JOAQUIN LOCAL HEALTH DISTRICT .. 1601 E. HAZELTON AVE., STOCKTON, CA cr'.`,I 1988 Telephone {209) 466-6781 f E.tiVIP-.9i%1.'.3TAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CNVfROMEtiTAL HEALTH E ��,.O1=S l;-�RE�'�'-t-�c�RVICES c r is t= 1! r ..�, ►=�Ft�'",!I�o�--r (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 t made in compliance with San Joaquin County Ordinance No. 549 for sewage or No.q182 for welUpump and th ules and Re ulations of the San Joaquin G Local Health District. ].,,, t �� '� � /J it Iter] Job Address City PM PM Owner's Name R Address � � Phone Contractor Address cense No. Phone TYPE OF-WEL PUMP: I NEW WELLr WELL„REPLACEMENT (J - `_._.DESTRUCTION ❑J, ._a_ F �. , ,. ' PUMP INSTALLATv� SYST RE AIR ❑ HE ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER`LINES •- :x `� DISPOSAL FLD PROP. LINE A �'� = " - �� AZ< OON.-1� �--AGRICULTUREWEL-L� RxWELL -0TS1SUMPS-__ -_,_ �_--- ” " INTENDED'OSE`""' " " jTYPE'OF WELL-- -PROBLEM AREA CONSTRUCTION-SPECIFIC TIO S. _-_ _...- 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casingp,/ +' omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing / Specificationsl r i ["1 Pub' Cl `Other L-] DeltaDepth of Grout Seal a of Grout, jl ligation _Approxi Dep --1 pastern N Surface Sea! Installed by Repair Work Done ElType of Pump ,` H.P. I State Work pone Well Destruction ❑ Well Diameter Sealing Material trop 501 ni Depth '� J Filler Material (Below 50'1 '' t:. TYPE OF SEPTIC WORK: NEWINSTALLATION 11 REf?AIR/ADDITION I I DESTRUCTION l L Wo `septic system permitted if public sewer is i` 3 # t available within 200 feet'.I Installation will serve: Residence_ Commercial Other Number of living units: �M I-Number of bedrooms r Character of soil to a dept of 3 feet: ' Watertable depth] ' ! SEPTIC TANK 1:1 O —€ Capacity s - No. Compartments ` PKG. TREATMENT PLT. D t `�" t P '+ MethodofDisposal Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ J No'& Length of lines € l•, Total length/size FILTER BED ❑ I Distance to nearestt: WeH Foundation Property�Line i SEEPAGE PITS I I Depth ."Size Number ' SUMPS�� ❑ Distance,to-nearest:,k . Well -.Foundation .-_ __.Property_ ine —s•. „ ��}�,� _ ;;_. DISPOSAL_ PONDS ❑ I hereby certify that l 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. 3 + 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 riot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'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 compen§a- tion laws of California." The applicant m t calf"for El r ed i pectipnS. Complete drawing on r rse side j Signed X - I� Title: 1� Date: ` r - _ ^- FOR DEPARTMENT LSE ONLY Application Accepted by _ ____Q�A—� 6 Date�,�7��♦�"� _ i4rea Pit or,Grout Inspection b1i; Date �. Final Inspection by_lt��ai+ •�7��tL..� Date 3 �x Additional Comments ❑'Stk 466-6781 0 Lodi 369-3621 0 Manteca a23-7104 0 Tracy 835-6385 a -� Applicant FletLAK all Copies io: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-., CA 9U01i ,4 r INFO AMOUNT DUE AMOUNT REMITTED ICK 0 CASH RECEIVED BY DATE PERMIT"NO. •y lI + EH 1324 iREV.1/"51J I,` �3 QG 1 y EH 14-2a O .7 I�