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tDroo APPLICATION FOR PERMIT R SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ae to the San Joaquin Local Health District for a permit to construct and/or install the Application is hereby madwork herein described. This application is anew with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wewpump and the Rules and Regulations of the San Joaquin made on is Local Health District. I �� Lot Size , !� PM 9 ff 1 r City Ih/"CJ `kJob Address �v ,I c - L q7 V,� d Address +� �- Phone Q Owner's Name -� t Phone_ `� - Address �14m& License No.�— T[ontraclos .�x _.DESTRUCTION ❑ 'WELL REPLACEMENT-❑ j TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _�-- PITSISUMPS CFi FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - �:. -J -. Dia- of Well Excavation Dia. r f Well Ca'sing ❑ Industrial ❑ Open Bottom ❑ Manteca- Specifications V I ❑ Domestic/Private ❑ Gravel Pack !�=❑ Tracy;; Type of Casing v Depth of Grout Seal � Type of Grout [-1 Public ❑ Other n Delta,! y _ s+ o ! ,.Approx-.;Depth I I Eastern Surface Seal Installed by I I Irrigation State Work Done Type of Pump' ump H.P. Repair Work Done ❑ TYP _ Seali - ial (top 50'1 '- t Well Destruction ❑ Well Diameter ng Materf Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION,i'I.DESTRUCTION .l_ No septc system permit i'vailablelvvthin 200 f ettled if public sewer is ![ installation will serve: Residence_ Commercial— Other_------r� + Number of bedrooms ` Number of living units: i - R Water table depth Character of soil to a depth of 3 feet: No. Compartment SEPTIC TANK ❑ Type/Mfg ~;Capacity • I Method of Di 4sal PKG. TREATMENT PLT. ❑ ^Pio ert Line ` Distance to nearest: Well Foundation P Y t Total length/size n LEACHING LINE ❑ No. & Length of lines Property Line W�J ❑ Distancel FILTER BED to nearest: Wel[ FoundationI 4 .1 Number I SEEPAGE PITS l 1 Qepth .� Size Property Line S! SUMPS 0 Distance,to nearest: Well Foundation P y DISPOSAL PONDS ❑ V this that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared rules and regulations of the San Joaquin and in Local Health Di?;trict, at in the performance of the work for which this permit is issued, I shall not 1 Home owner or licensed agent's signature certifies the following: "I certify th employ any person in such manner as.to become subject to workman's.compensation laws of California Contractor's sonslsub subject to work man 1s compensate certifies the following: "I certify that in'he performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." The applicant m for all required inspections. Complete drawing-on reverse sid ce. L ` Y Title: Date: signed X �\\ FOR DEPARTMENT USE ONLY 4k D01 ate _ \ �rea f Application Accepted by >7 t Date Data Final Inspection by Pit or Grout Inspection by �� 77 Additional Comments: 1 r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823 7104 ❑ Tracy 835-6385 Applicant Return all copies t:nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 1 _ FEE AMOUNT DUE AMOUNT REMITTEE] H RECEIVED BY DATE PERMIT NO. ' )NFO +_EH13-241REV.i/H5) EH 14-26