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Mit. . Y APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT E!' 1601 E. HAZEL—ION AVE., STOCKTON, CA I'1� Telephone (209) 466-6781 PERMIT EXPIRES I'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 weii/pump and the Rules and Regulations of the San Joaquin Local Health District. City Lot Size PM 4� ! Job Address Phone + Address _ Owner's Nam (p License N Z �x Phone Contrac 11Address E NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION TYPE OF,WELL/PUMP: °� SYSTEM REPAIR EJFLD. OTHER 13PUMP INSTALLATION ❑ + LINES DISPOSAL PROP. LINE SEWER i DISTANCE TO NEAREST: SEPTIC TANK. PITSISUMPS E! FOUNDATION AGRICULTURE WELL OTHER WELL it a i INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS - EM AREpia. of We11 Casing ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Specifications I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Depth of Grout Seal Type of Grout { FI Public ❑ Other Cl Delta _ f 4 I I Irrigation �._Approx. Surface Seal installed by Depth I I Eastern .j State Work Done H P — l Repair Work Done ❑ Type of Pump Well Destruction ❑ Wel( Diameter Sealing Material (top 501 0iZI Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I I a�ailabNo Pelwithin 200 feec system t.) if public sewer is Installation will serve: Residence Commercial _ Other r'- Number of living units: __L ;Number of r ms Water table depth Character of soil to a depth of 3 feet: 1 l Type/IV f � ��Method No. Compartments SEPTIC TANK- of Disp9sal ' PKG. TREATMENT PL ❑ : - --*�� 15-20 /� t' Distance to nearest: Well {5720 Foundation�� Property Line C �- O"` i Tota! length/size LEACHING LINE, No. & Length of lines x t � __ PropertyLine �{ FILTER BED: 4+` [I Distance^to nearest: WeII,;, Foundation n ,Depth Size i Number - — ! Property ne SEEPAGE PITS L SUMP5 C`1 Distance to nearest Well.4�� Foundation r+ ti DISPOSAL PONDS ❑ 1., It-,__.-.— I 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 4 i rules and regulations of the San`Joaquin Ldcaf-Health'Di'strict.- si•nature certifies the following: "I certify that in the performance of the work for which this permit is issu , Isshnlatu a no Home owner or licensed agents g .-- employ any.person in such manner as to become siibjeci to workman s compensation laws of California." Contractor's hiring or sub-contracting g ' certifies the following?'sl certify that in the performance of the work for which this Per .isti ed, I shall employ persons subject to workman's compensa i tion laws of California, The applicant mu t. all;for quired inspections. C6mplete drawing on reverse si e.� Signed X Title: Dater , FOR DEPARTMENT USE ONLY {I Date/ -" Area- Application,Accepted by- Date Fiiiatinspection by Date] Pit or Grout Inspection by ; t L AV 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i ffIZ CK RECEIVED BY DATE PERMIT'NO. UNT DUE AMOUNT REMITTED CASH la ♦.EH 13-24 IREV.t/H 57 � ! EH 14-26 [