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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. �Q Job Address Z Ci of Size �✓ �J f Owner's Name d Address Y -� License No. � 2-- Phone s. �i Contractar' Namey .-- TYPE OF-,W L/•PUMP. NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ `'�f► lJM ! STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO'NEARES SaiPTlr4t,�4 K, SEWER LINES DISPOSAL FLD. — PROP. LINE FOUNDATION 1 AGRICULTUREI, ELL ` r�, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST' &TION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well avation d ` _ ,. Dia. of Well Casing VIP ❑ Domestic/Private El Gravel Pack [T-racyT��ilre�of sin f j ` Specifications ❑ Public ❑ Other Ueptn of rout Sea f t - ❑ Irrigation _ Approx. Depth wrface al Installed by '� 1 Repair Work Done ❑ Type of Pump P• r �r Well Destruction ❑ Well Diameter 1i g terra o 50') ` Depth Filler Mate' I (Bel TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ DD 10 DESTRUN► "INo sdp'tic stemepi wer.is.,+ 4 +aavailal�A Vw'thin 2 �„�� j Installation will serve: Residence'L Commercial—_ 0 h +��` • f--- �i ��"" Number of living units: _/_ Numbpr of bedroqfnq k�11 1 a Character of soil to a depth of Water table depthQ SEPTIC TANK ❑ Type/Alf# Capacity Noompeym�r?ts'" s - 1 PKG. TREATMENT PLT. ❑ f Method f osall. Distance to nearest: Well 74 Foundation PrP ine�� LEACHING LINE No. & Length of lines Total length/size ( y F FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ } 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 District. # Home owner or licensed agent's signature certifies the following:; 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 laves-o CaCalifornia."Contractors hiring or sub-contracting signature;. certifies the following:"I certify that in the performaned o the work for which this permit is issue'd%l- all employ persons subject to workman's compense-- tion laws of California." f '+� The applicant mus all uir ctio . Complete drawing on reverseid�. r� Signed Title: - 4 Date:IF / � �,j R DEPARTMENT USE ONLY Q Application Accepted by Date Area } Pit or Grout Inspectio b Date Final Inspection by Date Additional Comme s: y ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Retur all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk_ CA 95201 f " -►++� FEEAMOUN7=�llEi "r`ANIt)1)F1T'REAIIn YED' 'M "�"'1;ECt IVEt)`BY— —VATE"� PERMIT'Nb. INFO +EH 1324(REV.10183E ER 14-28