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r r =--a......... T APPLICATION FOR PERMIT SAN JOAQd1IN LOCAL HEALTH DISTRICT 1601 E, HAZE T ON AVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED f .(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 ri .. City Size _ PM _ F Owner's Name Address Phone- Con h one �r Contractor E dress �/ Z TYPE OF WELL/PUMP: ! - Li cense No., Phone 4 NE WELL ❑ WELL REP,yLACEMENT p' • TAiLATlON 11 ,y1DESTRUCTION PU P INSSYSTEM REPAIR ❑,' °�# � OTHER EJDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION"'"""—A;GRICULTUh WEL�--L'"""""""""' INTENDED USE " ` - OTHER WELL PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ ❑ Open Bottom ❑ Manteca ` Dia. of Well,Excavation # ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing Type of Casing , \ + ❑ Public ❑ Other ❑ Delta Specifications �t Depth of Grout Seal'-- Cl Irrigation _Approx. Depth ❑fastern ` Type of Grout '; I Surface Seal-Installed by , Repair Work Done ❑ Type of Pump� �� H.P.- Z- Well Destruction —,State Work,Done Well,Diameter Sealing Materia! (top 501) Depth r Filler Material /Below 501 TYPE OF SEIN-PTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU ION :. ❑ o septic system permitted ' public sewer is Installation will serve: Residence Commercial available'witfiin 200 feet.] ; Other j Number of living units: ` Number of bedrooms I 1 Character of soil to a depth of 3 feet: ; SEPTIC TANK ❑ Type/Mfg Water table depth PKG7TREATMENT-PLT:-E1 Capacity_._ No. Compartments Method of Disposal - Distance to nearest: Well Foundation9 t Property Line t LEACHING LINEt l ` ❑ No. & Length of lines ?" FILTER BED Total length/size i. ❑ Distance to nearest:- 4, WellFoundation °Property Line-� F ` r SEEPAGE PITS EJ Dei th ' * - � t ' p Size Number SUMPS EJ Distance to nearest: Well 1 DISPOSAL PONDS `� ~ �'_w. Foundation -.-'Property Line 1 ❑ IT ! ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Jaws, and rules and regulations of the San Joaquin'-Local Health District. : ; 1 _ 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, shall'not ry employ any person in such manner as to rtiecome subject to workman's compensation laws of California."Contractor's hiring or suti-contracting signature certifies the following: 'ill certify that in_the performance of the work far which this permit is issued, !shall employ person's subject to workman's comperisa- + f' tion laws of California.c !�v The applic ust c r .required-inspec ions. Complete drawing ow rave side. Signe it1e: r' t Date: C FOR DEPART NT USE ONLY Application Accepted by 1 [ ' Date :Z (OA a Pit:or Grout Inspection by 1 / Date Final inspection by r Additional Commi s: Date ents: 1 } 7 Stk 466-6761 ❑ Lodi 369-3621 }❑ Manteca. 823-7164. Y E ❑ Trac 835-6385 } plicant—Return-alfcoPes to. Environmentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95207 r• FEE AMOUNT;DUE AMOUNT REMITTED Y SCK F r INFO CASH RECEIVED BY DATE —PERMIT'NO. + EH 13-24(REV.t A 5)