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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. l s. Job Address City Lot Size PM I r Owner's Name 3 dress Phone ' nae No. Panne�f Contracto Address TYPE OF WELL/PUMP: N W WELL f` W LL REPLA MENT DESTRUCTION ❑ 1 PUMP INSTALLATION SYYT: OTHER ❑ f I DISTANCE TO NEAREST: SEPTIC TANK EWER LINESDISPOSAL FLD/,_--- PROP. LINEFOUNDATION � AGRICULTURE OTHER WELL PITS/SUMPS 1 INTENDI USE TYP WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S 111ha pen Bottom El Manteca Dia. of Well Ex n Dia. of Well Casing tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing specifications❑ Other f-1 Delta Depth of Grout Seal Type ofGrout on iApprox. Depth l 1 Eastern Suifaee Seal Installed by ork Dont ❑ Type of Pump H.P. State Work done r Well Destruction ❑ Well Diameter — Sealing Material Itop 501 Depth Filler Material (Below 501 -- i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other f' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK! " ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r c Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � w SEEPAGE PITS 1 1 Depth 5iie _ Number ( SUMPS ❑ Distance to nearest: Well f Foundation• f� I Property Line DISPOSAL PONDS I hereby'certity that I have prepared this rapplication and that the work %Wilhbe one in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di%trict` f Home owner or licensed agentfs signature certifies the following: "I,certify that in the performance of the work for which this permit is issued, I shall not empldy'any person in such maKner.as to become subject to workman a 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 compensa tion IaWi of Galifo'rnia.'.' The appli a m t all for al requi i specti ns. Complete drawing�onjs", �, i Signed X r Title: 4 Date: �. FOR DEPARTMENT USE ONLY Application Accepted by y Date "2'1 y Aroa Pit orut Inspection by Date�f�� Final Inspection by Date Additiiionndal Comments: t ' ❑ Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE— ---- - „ .� ..«�� _CK' EE AMOUNT BUE AMOUNT REMITTED CASH RECEIVED SY t �pA7E y- PERMIT'NO. INF IL I +.EH 1321(REV.t/x 5) /�f t� T ' - N )g EH 11-26 V {