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u APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 ,l 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. jl ii ` Job Address 4;1 �. 4�1&4e_ ',.4ve_ City =• oijf Lot Size �- PM h ,�[ i , Owner's Name . �3*L Address 6711 � Ah Al.., Phone � ' � ? Contractor �i Address fi F License No. Phone TYPE OF WELL/PUMP: .r WELL El WELL REPL'ACEMENT`❑ DESTRUCTION El PIJ @S N 101SYSTEM REPAIR'❑ OTHER ❑ DISTANCE TO NEAREST:IvPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ;�FOUNDATION GRICULTURE WELL m OTHER WELL PITS/SUMPS _ k INTENDED USE TYPE OF WELL PRCIPtLIT4 A CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom C1 Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ 174rky Typ f Casing Specifications 4 FI Public F Other Ll Delta Depth o rout Seal -' #-_ 'Type of Grout I I Irrigation _'.Approx. Depth t Eastern Surface Seal Installed by' _ Repair Work Done ❑ T p p Type of Pum H.P. _ E x'State..Work Dane _ Well Destruction ❑ Well Diameter Sealing Material'(top 501) Depth Filler Material (Bel6w.50') _ p� TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ADDITION Joe- DESTRUCTIONI I INo septic system permitted if public sewer is f / Wiz. available within 200 feet.) Installation will serve: Residence✓ Commercial_ Other *-' Nuinber of living units: _/_ Number of bedrooms Character of soil to a depth'hof 3 feet: _ ' ar v4 j ;:i s^`i Water table depth I1 + - SEPTIC TANK ®`Type/Mfg i:.7 <; i ' . Capacity_ _ No. Compartments 2f .jPKG. TREATMENT PLT. ❑': z Method of Disposal yDistance to nearest: Well `/' I Foundatlion Property LineL fry LI r ;3 -s: '4 r_Y ,-i tl- -'h 4' Y' L'! s`'r �i' 3 •.� i .. r r { LEACHING LINE ❑ No_ & Length of lines Total length/size ;. t}.. ' FILTER E 0" Distance to nearest: Weil r_j�t] _+Foundation 1 t.) r' property Line' SEEPAGE PITS I i Dapth Size ,Number F SUMPS ❑ Distance to nearest: Well " Foundation ' Property Line DISPOSAL PONDS ❑ �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 Di§trict: r _� 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 become subject to workman's 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 laws of California." The applicant must call for.all`required inspections. Complete drawing on reverse side. SignedTitle:,',', Date:t- r� FOR DEPARTMENT USE ONLY it Application Accepted by �' 1 Date a Area II ` Pit or Grout Inspection by Date Final IInspection by Date E Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r w FEE INFO AMOUNT DUE {'AMOUNT REMITTED- .- CK H- - RECEIVED'BY DATE ' PERMIT NO. +.E1 3.24(REV.r/n5) d5 ,� OEH 1 7 -70 gyp/