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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA No kv Telephone (209) 466-6781 PERMIT EXPIRES 7 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. , Job Address City 4?! /'J Jed'Lot Size PM 1Ifi brims--+ Owner's Name LT� �E1 _ Address Phone Contractor Address ? License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ° [3 Industrial El Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic lPrivate ❑ Gravel Pack ❑ racy Type of Casing Specifications 1-1 Public ❑ Other Ll Dto Depth of Grout Seal Type of Grout _ 1 1 Irrigation T-Approx. Depth i I East n Surface Seal Installed by Repair Work Done ❑ Type of Pump P. State Work one Well Destruction ❑ Well Diameter Se ling Material (top 501 Depth Y _k Filler"Material (Below 50')-- TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is F available.within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms s Character of soil to a depth of 3 feet: r: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ h. I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length,of lines `Total lengthlsize- ' �. / .= FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I l Depth _Size_ _ _ _(, _ m Number 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 District. 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."Contractors 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 reqpired i spections. Complete-drawing on reverse side. Signed X ! Title: awe a'i Date: _L._..__`^4 le JF1 D TMENT USE ONLY +� Q Application Accepted by Data b^�` ` 7 Area _ Pit or Grout Inspection byD�a Final Inspection by Date Additional Comments: �� _ ❑ Stk �466-6781 ❑ Lodi 369-362f ❑ Manteca' 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 4 t,7ffE --AMOUNT''° _.. GK_ ,,v,.�.. F- ,,..,s•-� -.► „�-- �-O. UNT DUE AMOl11V7`REMlTTE�— RECEIVED BY DATE PERMIT NO. S H-= ♦ EH 13-24 IREV.i/H 57EH 14-2e