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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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ors Job Address 1 City n Lot Size PM Owner's Name Address }Q4rrtit C(S62 Phone441 ��/�� rbn Contractor s �S66� ense No/_M; %-Phone��/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o ng Specifications ❑ Public ❑ Other ❑ Delta Depth of Gr eal A Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ` rt• - Repair Work Done ❑ Type of Pump H.P. State Work bone k;, Well Destruction ❑ Well Diameter Sealing Material (top 50') , Depth filler Material 16elow 50'] TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION 29 DESTRUCTIO (No septic system permitted if public sewer i 1 available wit in 200 feet.l �Z Installation will serve: Residence X Commercial L�Other � � °� ° � Number of living units: � Number of be rooms 1 � - Character of soil to a depth of 3 feet: �� fi' r.s s Water taljte'depth' 76" W) (Lkleq� SEPTIC TANK ❑ Type/Mfg Pit L 'Cas3nh4 s Capacity_ -c No. Compartments PKG. TREATMENT PLT. ❑ 1 r Method of Oiiposal Distance to nearest: Well Foundation Q Property Line __ 1 LEACHING LINE >�,No. & Length of lines fs Total length/size FILTER BED ❑ Distance to nearest: Well / fOAation d _� Property Line / /iSEEPAG7OE PITS ❑ Depth Size Nu ber SUMPSx Distance to nearest: Well ,Foundation Property Line DISPOSAL PONDS ❑ 9 " ' ' C f 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 thetWork 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.':Contractor'§hiring 8k.sub-contracting signature certifies the following: "I certify that in the performance of the work for which thii permit is issued,-I shall employ persons subject to workman's compensa- tion laws of California." ,k-.1 ,, F. The applicant st call r II required ins tions. Complete drawing on reverse side. Signed r ?^$ 7 9 Title:' II/�! ti. "Date: F ARTMENT E5 ONLY Application Accepted by ! Date Area .' 1 i,* . Pit or Grout Inspection by Date Fi' al Inspection by Data Additional Comments: s� ti LC ❑ Stk 465-6781 Lodi 369-3621 ❑ anteca 823-7104- Tr y -83 6385 Applicant- Return all copy to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box ,•Sf-, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO, + EH 13-24(REV.t/R5) - { � EH 14r0�28 D✓ ' ! 3 4 _ d