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N :-a � APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) c 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 h I Local Health District. I f Job AddressC7 7142 < City�� Lot Size I c M Ir _ Owner's Na ddress � � Phone Camra License No — Pho { TYPE OF W L/PUMP: NEW WELL ❑ WELL REPLACEMENT, ❑ DESTRUCTION O "PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK J ;SEWER LINES DISPOSAL FLD. PROP. LINE iJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j 4 ❑ Industrial ❑ Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing ` f F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C'l Public ❑ Other .1� Cl Delta Depth of'iGrout Seal Type of Grout r — I I Irrigation ..—."Approx. Depth I.I.Eastern tiSurface Seal Installed by. _ Repair Work Done ❑ Type of Pump H.P. f A State Work Done:_, { Well Destruction ❑1 Well Diameter Sealing Material {top 501 s ` "Depth 7. Filler Material (Below 501 i > TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I DESTRUCTION 1 I INd septic system permitted if public sewer is available within'2004eet.) .. Installation will serve: F ResidencAmber Commercial Other Number of living units: t �,��•..� �+ 1., (��\ of bedrooms Character of soil to a depth of 3 feet: ` ^- F Water table depth i I Type/Mfg p. SEPTIC TANK T YP g Capacity No. Compartments. , i PKG. TREATMENT PLT. ❑ ,Method of Disposal Distance to nerest: WellA 'r Foundation 1- Property Line LEACHING LINE No. & Length of lines _- � Total length/size s /��,� r� � Foundation J f P FILTER BED ❑ Distance to nearest: r Well roperty Line t t. SEEPAGE PITS >41 Depth Size Number f` SUMPS 0- Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i C r 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•Di%trict. 1. f s Home owner or licensed agent's signature certifies the following: "I certify that in the performance of:thework 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."Contractors 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 person's subject to workman's compensa- tion laws of California." -,- .1 , w, - ` The applicant must calf for all requir ins ctions. Comply drawin on reverse side. Signe � g Title, _ Date: r ENT USE ONLY - m Application Accepted by f Data LA -v —_ Area —� I it or Grout Inspection by Date �ZSFinal Inspection by Date lib 1- 9 a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUET AMOUNT REMITTED CK IT CASH EH RECEIVED BY DATE PERMIT"ND. I a.EH 14N-2B-26/REV.t/x 51 !� t Q6_0 / f�� /? iZ D 74� I 6 111 r 1 1