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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZI_LTON 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 theRulesand Regulations of the San Joaquin I Local Health District. ; gip c,L fj 1 u i7 a C - " 7"`3(z p r �. elf�,fh 0 A"Clty Lot Siz 70X aO- PM Job Address �f ! / � ns S - Address l �a Phone Owner's Name �1/ L�1 Contractor's Name -e License No. Ar/ Phone /i 4W�5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,,K PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,9 ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ,�OTHEWWELL;w _ PITSISUMPS��_'� r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICTiONS �* 1-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well CasingI + D Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications-,,, ❑ Public El Other ❑ Delta, Depth of Grout Se 1--' - Type of Gfout _ r ❑ irrigation —.Appmx. Depth ❑ Eastern Surface Seal installd; wby //� SIL yA Done Repair Work Done E3 Type of Pump H.P. telae Work SealingMaterial (top Well Destruction X Well Diameter /� 50') Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION © [No septic systB'm permitted if public sewer is available witfii 00 feet.) �- Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet: ' `VVeter tab{e;depti SEPTIC TANK ElType/Mfg' Capacity NoACom rtments PKG. TREATMENT PLT. ❑ `JIAet of Disposal a Distance to nearest. Well Foundation Pro e Line I LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size NJIEn SUMPS 11 ''Distance to nearest. well Foundation i Properti 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 ordilrtances, state laws, aitd11- "" rules and regulations of the San Joaquin Local Health District. j i � rk for which this pePmit is issued,I shall o I Home owner or licensed agent's si nature certifies the following: "I certify that in the performance of the wo employ any person in such manner s to become subject to workman's compensation laws of Califomia.�i Contractor's hiring or syb-contracting s'rgnatur � 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 compen s" tion laws of California." The applicant must call for al uired inspections. Complete drawing on revs side. Date: I Signe + r I FOR IDEPARTMEN USE ONLY CIO 3 II I Accepted b a Dat - Area• x ApplicationP Y Pit or Grout Inspection by Date Final Inspection by{ ,Date' I Additional Comments: �� llama ❑ Stk 466-6781 ❑ Lodi 3W34 ❑ Manteca 823-7104 ❑ Tracy 835 638 ` Applicant- Returnall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,Pf ...o> 2009, Stk., CA 95201 I FEE7 AMOUNT DUE AMOUNT REMITTED CASH RECEIVE $( OATS PERMIT"NO. INFO f� + EH 13 . e"24(REV.10183) _ _ ��fa EH W28 i