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APPLICATION FOR PERMIT Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. -HAZELTON '`AVE.,.STOCKTON, CA ; Telephone (209) 466-6781 p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , (Complete in Triplicate)" f Application is hereby made to the San Joaquin Local Health District far-a-permit_to can struc't`and/ar-install the work herein described."Tfiis application is made in compliance with San Joaquin County Ordinance No:'549 for sewage or No. 1862 for well/pump and the GVWand Regulations of the San Joaquin Local Health District p. r no Job Address y City k1 " Lot Size �" PM " Owner's NameAdd�ess ((� 'z�2-�z /s/�� 1 Phone Contractor 1 _/, r�� ;:5 V:5: Address %Ill License No, Phoner TYPE OF WELL/PUMP: . NEW WELCM WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION .e 'f " SYSTEM REPAIR ❑ OTHE? ❑ DISTANCE TO NEAREST: SEPTIC TANK _ LtVA SEWER SINES _-�� DISPOSAL FLD.J PROP. INE FOUNDATION 3s AGRICULTURE WELL f3THER WELL ---PITS/SUMPS 11;revy INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS ❑ Industrial LJ Bottom ❑ Manteca:, �_ Dia. of Well Excavation�Z Dia. of Well Casing �`• r Domestic/Private ,Gravel Pack ❑ Tracy l Type of Casing Specifications 'Ro❑ Public . " ❑ Ot}1er ❑ Delta ` ty AACAemwaYZ Depth of Grout Sealy Type of Grout ❑ Irrigation ; Approx. Depth ❑ Eastern - Su d by ce Seal Installe Repair Work Done ❑ Type of Pump H.P,' State Work Done Well Destruction ❑ Well Diameter Sealing.Material Itop 501 E t Depth Filler.Meterial (Below 501 TY,P�E.OF'SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,AD,DITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is `� -{ 4; i •' available within 200 feet) L !. st In w v �. E : allation will serve: Residence_ Commercial€ Other ' ln F 4 }• Number of living units: Number of bedrooms I ' Character of soil to a depth of.3 feet: t ft b"� tt.: " Water table depth, SEPTIC TANK ❑ Type/INfg f # ` ' • 1 Capacity No. Compartments41" = j PKG. TREATMENT PLT. EJy j r� {# y _ Method of Disposal 1 Distance to nearest: Well } .- 1" Foundation$' �Propa5y_Line T � 4LEACHING LINE 01 No.•& Length of lines [ `` "t t Total length/size I FILTER BED ❑: Distance to nearest:" Well 1-�- Foundation Property Line i SEEPAGE PITS 17 Depth 1 Siie yrr f Number t _ 1 atm SUMPS L1 Distance to nearest. Well ` r Foundations" Property"Line i :- 4 DISPOSAL PONDS I hereby certify that I have prepared this application and that the walk will be done in with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.) ;. Home owner or licensed agent's signature certifies the followind: "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 compensation laws:of_Cal'ifornia." 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 persons subject to workman's compensa- tion laws of California."' t t.4 ,A il The applicant m j c �a requir ;ctions. Complete.drawing on re ers ideI. I . t Signed lTitld ` " Date: t t 1 } r FORt-,M_ MENT USE ONLY , - I . . Date : Area. Q Application Accepted by „4,fi - 1 d t ' Pit or Grout Inspection by/' Date - Qi Final Inspection by Date < / " 1 4 � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca wE23-71D4 ❑ Tracy 835-6385 w. Applicant- Return all copies to: Environmental Health Permit/Services-1601_E. Hazelton Ave., P.O." e ci eB. 09,2009, Sika, CA"95201 1 ' FEE M ---- •DATE. PERMIT•NO. INF UNT DUE AMOUNT REMITTED' CK 'RECEIVED BY l - 1 o CASH I. + EH 13-241REV,1/85l e EH 1428 t