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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA c 1,Telephone [209) 466-6781 PERMIT EX I?IRES 1 YEAR FROM DATE ISSUED jJi IComplete 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 N61'549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City MMOkot Size `-� �PM t a Owner's Name C, Address � v L Phone Qontracto I"_%_/M__1A_04 Address C0ll !C License No. 4 Phon 8e0l7v 1 TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEM T ❑ DESTRUCTION ❑ PUMP INSTAL TION ❑"" "'"`y SYSTEM REPAIR El• —OTHER�© - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISP PROP. LINE FOUNDATION %GRICULTURE WELLS OTHER WELL PITS/SUMPS INTENDED USE TY>WELLO EM AREA TRUCTION SPECIFICATIONS❑ Industrial ❑ OMante' Dia. of Well ExcavationDia. of Well Casing ❑ Domestic/Private ❑ Gacy Type of Casing Specifications 1-1 Public l Cl ODelta 1epth of Grout Seal Type of Grout I I Irrigation _ Eastern Su ce Seal Installed by Repair Work Done ❑ Type of Pump ; 'H-P. State Work Done _ Well Destruction; ❑ Well Diameter i I Sealing Material (top 50') Depth j Filler Material {Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I IREPAIR/ADDITION I.I--DESTRUCTIO (No septic system permitted if public sewer is l�J t available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedr oms IIII , Character• of soil to a depth of 3 feet: Water table depth SEPTIC TANK i ❑ Type/Mfg _ A .�� i Capacity_ UO No. Compartments PKG. TREATMENT PLT. ❑ ; I'EEEEE f Method of Disposal Jj x 4� fff V Distance to nearest: Weir �+�"" Foundation G � Property.Line LEACHING LINEi ❑ No. & Length of lines To al length/size FILTER BED I O Distance to nearest: Well 46 t!•_" u_ndation-.�• Property Line I I SEEPAGE PITS i I Depth Sizell 3 M Number SUMPS Ll Distance to nearest: We11 Foundation Property Line DISPOSAL PONDS ❑ .. Jr, �•'.e+� . 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 rules and regulations of the San Joaquin local Health DR.r. . y 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 became subject tojlworkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I rtify that.in the performance of the wbrk for which this permit is issu i k shall employ persons subject to workman's compensa- tion laws of Californi The applic ust all uired i do Complete drawing 01 e erse side. ILII Signed Title: Date: FOR DEPARTMENT USE ONLY rr is Application Accepted by I A'*rt Date Area Pit or Grout Inspection by DateFinal Inspection by. e^-�L�"—a�G- Date _ illi Additional Comments: ❑ Stk 466-67811 C Lodi 369-3621 LI 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 FEE AMOUNT DUE AMOUNT REMITTER RECEIVED BY DATE PERMIT NO. INFO it C ♦ EH13-24 IREV-1/8 5) EH 14-28 .��