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r APPLICATION FOR PER MIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED _ 3 w.: (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. Joh Address City _ Lot SizeC9 PM Owner's Name 4gjn42_!L(,5- Address Phone *� Contractor �- L Addres «>7,. � License No. Phone TYPE OF WELL/PUMP., 4 ;5-w-- - W WELL ❑" WELL REPLACEMENT ❑�`' wDESTRUCTION ❑ , l - PUMP INSTAL ION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL PITS/SUMPS I INTENDED USE I TYPE OF WELL PROB M A CONSTRUCTION SPECIFICATIONS h ❑ Industrial ❑ Open Bottom ❑ ec Dia. of Well Excavation, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type'of Casing ` cyg # ' Specifications Publip:i' ❑ Othe ❑ Delta Depth of Grout Seal f Type of Grout «E Irri abon a s g f pprox.�Depth ❑ Eastern ace Seal Installed by Repair Work Done ❑ _ ype of Pump P �""" "` ^,- Sta$e Work pone 1 "!Well Destruction ❑ Well Diameter Sealing Material {top 50') 1 '. Depth Filler Material (Below 50') x' J . f ,�TYYPE OF SEPTIC'WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted if public sewer is 66ll"within.200 feet./ f'� -,,,Installation will serve Residence Commercial Other _ �:5 U R Number of living units: ,Number of bedrooms Character of soil'to a depth of.3 feet:. Water table depth _ SEPTIC TANK 5-^3 ❑ T fgi Capacity e'J No.'Compartments PKG:TREATMENT PLT. ❑ T----.Method ofDisposal Distance to nearest: We'll Foundation Property Line '( { $ T LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: WellFoundation Property Line ' SEEPAGE PITS i ❑ Depth -S ize Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r, DISPOSAL PONDS ❑ I. I hereby certify that I have prepared this application and that the ork will 66-done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.---- ` ` T _ 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 compensa'tion.taws 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 compensa- tion la4vs of California." . The applicant must call for all required inspections. Cpm drawing on reverse side. Signed Title: Date: OR DEPARTMENT USE ONLY �1 Application Accepted by a Cf/1 DateAre. Pit or Grout Inspection by t Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ " c f 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE INFO AMOUNT DUE F AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. CASH +EH 1324(REV.5/B 5) �S EH 14-28 ^ - �7f�7 157-- JJ 1 � !