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r 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) 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;Ordiria' a N8;;549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin - Local Health District. Job Address 6^405-_ 6S s, - 636 3 .r.��a�w 44frl�a ��city Lot Size /��C O w PM Owner's Name a Address Phone Contractor Address License No9MQ016Phone TYPE OF WELL/PUMP: .ANEW WELL ❑ WELL REPLACEMENT ❑ � -DESTRUCTION ❑ ti PUMP INSTALLATION ❑ . +,SYSTEM REPA ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S-�,W LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC' URE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA NS, UCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack d ❑ Tracy pe of C Specifications (1 Public ❑ Other _ C1 Delta Depth of Grout Type of Grout + t I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H. . State Work hone — Well Destruction ❑ Well Diameter ealing Material (top 50') s _ , A Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I- DESTRUCTION I `(No septic system permitted if public sewer is i i f vailable within 200 feet.) Installation will serve: Residence .Commercial_ Other Number of living units: -.—Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ TypelMfg 1' Capacity No. Compartments PKG. TREATMENT PLT. ❑ a { Method of Disposal f" Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ ' No. &'Length of lines Total length/size FILTER BED ❑ Di Mance to nearest: Well Foundation_ Property Line SEEPAGE PITS ( I Depth Size Number SUMPS i�.Cl Distance to nearest: Well Foundation Property Line C DISPOSAL PONDS ❑ I hereby certify that I hake piepared this.application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and.1� 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, l shalt 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, r 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." t The applica ust call for all required inspections. Complete drawing on reverse side. Signed X - Titke:. id�r� Date: R i F ENT USE ONLY E R Y _tD` � . Application Accepted by n��_ Data Area s � I Pit or Grout Inspection by Date Final Inspection by � Date Additional Comments: , ■ dt D AL �� d O A_LC1 ❑ Stk 466-67811 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ fracy 835-6385 Pi- Applicant - Return all copies to: Environmental Health Permit/Services 1601E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEEAMOUNT DUE AMOUNT REMITTED CK )NFO RECEIVED BY DATE PERMITNO. \r, + EH 13-24(REV.)/N 51 �7� S•.r"' EH 14-28 N