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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 I YEAR FROM DATEISSUED (Complete in Triplicate} Application is hereby made to the San Joaquin Local Health District fora 1 made H compliance with San Joaquin County Ordinance No.549 for Permit to construct and/or install the work herein Local Health District. �!3 � � sewage or No. 7862 for well/pump and the Rules and R `fescnbed.TI"&aPPlrcatron is s d �'�Q'�✓ t �+ Regulations of-the San Joaquin 1. Job Address City qC' Lot Owner's Name 'L !" ..size. PM - Address Contractor Phone --.,..�-..-. � .�... TYPE OF WELL/PUAddress MP: License No NEW WELL ❑ WELL REPF;ACEMENT,❑ � .. a� Phone DESTRUCTION CIf —"" PUMP-)NST;4LL-ATION--p � 1' rj 4 DISTANCE TO NEAREST: SEPTIC TANK SYSTEM-REPAIR-EJ---*— .OTHER p SEWER LINES -.-- I Fp{1NDATION ��— DISPOSAL FLD. ! AGRICULTURE WELL PROP. LINE INTENDED USE `," " -y-.R.._ pAd- ---- OTHER WELL PITS/SUMli TYPE OF WELL PR08L�,^-CONSTIiE1CTI0N SPECIFIC4TI�I�54 € ❑ Industrial ❑ Open Bottom ❑ Domestic/Priate ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack Q Tracy 'T ` " � Dia. of Well Casing ❑ Public Type of,Casing j ❑ Other O Delta-" "" Specifications ❑ Irrigation DepiFi of Grout Seal-t ? —APArox.,Depth ❑ Eastern Type of Grout Repair Work Done ❑ Surface Seal Installed iby Type of Pump H P r Well Destruction' '❑ Welj`Diameter`"�_ States Work Done t } Sealing Materia! (top 51 z jJ Depth Filler Material (Below 50') f 1lr TYPE OF SEPTIC WORK: NEW INSTAL TION REPAIR/ADDITION ❑ DESTRUCTION p (No septic system er G µ Installation will serve: Residence. 1 p. p matted if public sewer is 0 � e 1 Commercial available within 200 feet. Number of living units: r - t Other�� Number f b, rooms�� Character of soil to a depthf of 3-feet, SEPTIC TANK ¥ - ' u ❑':TYpe/Mfg ' ' Water table depth r PKG. TREATMENT PLT. ❑ $ Capacity i is No. Compartments E 't Distance to nearest: Well / Method of Disposal t r Foundation ` Property Line LEACHING LINE ; No. & Length of lines 9 FILTER BED v ❑ Distance to Well Foundation nearest: T� P i Total length /sizetY 6 F x Pro a Line 1 i r SEEPAGE - € � f�-f ❑-•�,L�epth � Size - SUMPS ❑ Distance to nearest: well�` Number DISPOSAL PONDS ❑ Foundation�� Property Line I 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 la rules and regulations of the San Joaquin Local Health District.Home owner or licensed agent's signature eerti#les the following: laws, and # employ any person in such manner as to become subject,to workman's compensation laws of California."Contractors Kirin or sub contracts t "I certify that in the performance of the work for which this permit is issued, I shall not certifies the following:"I certify that in the tion laws of California." Performance of the work for which this permit is issued, I shall employ g ng signature 1 i P y Persons subject to workman's compensa- The applicant must call for al required inspections. Complete drawing on reverse side. Signed �- ' - Title: Date: { FOR REPARTMENT USE ONLY Application Accepted by l 3� � � 3 ! f� Pit or Grout lns Date Npection by Area Date i Final Inspection by //�� Additional Comments: Date A?- ; ❑ Stk 466-6781 i ❑ Lodi 1369-3821 . ❑ Manteca 823-7104. Applicant- Return all copies to: Environmental Health Permit/Services 1601 EII Hazelton AO Box 2009, r Stk., CA 95201 - FEE INFO AMOUNT DUE' 1 i AMOUNT REMITTED CK l CASH RECEIVED BY DATE + EH 1324fREv.vagi a PERMIT''NO. EH 14.28 , �'O. b - a