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Dis '4r1�g 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) .cation 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 App' s made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and�WF of the San Joaquin � District. Local Health +� 4 city °� oil Size PM � Joh Address - � Phone 7 �� Address / Owner's Name � I O f,�,�rSdw4/ License No. —Phone �� 5d � Address �� ' Conttactor WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELLIPUMP: NEW WELL El ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER SEWER LINES �� DISPOSAL FLD. POOP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS —f FOU�N6ATION� AGRICULTURE WELL i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing I .-Dia._of_Well..Excavation 0 industrial ❑ Open Bottom Cl Manteca Specifications ❑ Gravel Pack ❑ Tracy i Type of Casing ❑ Domestic/Private Type of Grout — F 1 Public 17 Ot her 0 Delta Depth of Grout Seal i Surface Seal Installed by I Irrigation --Approx..Depth I I Eastern I , H.P. State Work Done _ Repair Work Done ❑ Type of Pump d ' ^ -.1NeIl Destruction: 0 Well Diameter Sealing Material (top 50'1, Depth ( Filler Material (Below 50'1 TYPE OF SEPTIC WORK:;�NEW INSTALLATION I'i REPAIRIADDITION DESTRUCTION I 1 lNo septic system permitted if public sewer is 1 „i available within 200 feet.( t , Installation will serve: Residence Commercial— Other, - Number of diving units: t2— Number of bedrooms ,3 UF Water table depth Z ! y Character of soil to a depth of 3 feet: ` "" o:'NCompartments I SEPTC TANK l Type/Mfg �L C o''C�>✓f'� "- - Capacity i TMethod of Disposal PKG. TREATMENT-PLT. LJ ' 1/0Oiil Property Line �o'r'' t Distance to nearest: well Foundation Total length/size LEACHING LINE ❑ No. & Length of lines �__.Prcperty Line 0 4 r Foundation FILTER BED { ❑ Distance to nearest: Well r I Number-- I I SEEPAGE PITS l 1 Depth Sire _ ` SUMPS L1Distance to nearest: Welt Foundation 'Property Line DISPOSAL PONDS ❑ ` 'k � I hereby certify that i have prepared this application and that the work will be done in accordance withSan Joaquin county ordinances, state laws, and l not rules and regulations of the Sari Joaquin Local Health ies the following: lio ingt. tt Work for this permit is issue Home owner or licensed agent's sig s torbecome subject workman'srtcoympansatthat in ion lawsoof California." Contractor's1hiring or sub-contracting lsignlaturre employ any person in s 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." I The applicant st call for all required inspections. Complete drawing on reverse side. / Date: Title: t Signed K r OR DEPARTMENT USE ONLY Date Area Application Accepted by Final Inspection by Dat Pit or Grout Inspection by Date f , Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823 7104 ❑ Tracy 835 fi3B5 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE -„"AMOUNT DUE —AMOUNT REMITTEIS 4-CASH ftECE111ED B f DATE PERMIT NO. ' INFO 2•y 1„ —7p• (Do s� +tW r.EH 1724 IREV.t�H sf , EH 14-2e s —