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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCK7ON, CA Telephone (209) 466-6781 ii PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :c (Complete in Triplicate) 1 Application is hereby made to the San Joaquin Local Health District for a permit described.This application is mit to construct arfd/or install the work he made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62#or weN ump and the Rules and Regulations of the San Joaquin Local Health District., iE, Im� .� a G Lot Size �� s PM city � � a Job AddressKyg ,: I �� Phone Owner's Name- Address +ice`j Phone Contractor's Name f License No. TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMPt INSTALLATION ❑ SYSTEM REPAIR ❑ ai' . OTHER ❑ �� °• SEWER LINES A— DISPOSALLL FLD�>� PROP. LINE jpISTANCE TO NEAREST:i•'SEPTIC TANK •ry !i OTHER'WELL t PITS/SUMPS n j FOUNDATION AGRICULTURE WELL v INTENDED',USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 IE ' Dia. of Well Casing ❑ indestrial ❑ Open Bottom ❑ Manteca- Dia. of Well Excavation ° w i. i' J i Specifications C3E3 Domestic/Private Gravel Pack ❑ racy_P " .TType of Casing y Tri " Type 9VGr6ut [� public ❑ Other, ❑ Delta Depth of Group Seal I F �fth ❑ Eastern Surface Seal Installed by I ❑ IrriglationpProx. Depth f State Work Done # f' Repair Work Done ❑ Type of Pump H.P. ?I Sealing Material (tap 50 Well Destruction ElWell Diameter Depth Filler Material (Below 501) eun` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ll DESTRUCTION C1f(Nailsepliwthst m p 20D feet if public sewer is 1 I� 0, installation will serve: Residence� Commercial— Other_�� ,, !� Number of living units:_.�- Number of bed o om; t i F • i 1 Water table 'depfK Character of soil to a depth of 3 feet: �+ ' �_ SEPTIC TANKS �1 TypelMfg 4 � S� __ Capacity 00 i No. Compartments Method of Disposal a PKG. TREATMENT PLT. ❑ 1G 1-0- '�'r Property/Q �0 Distance to nearest: Well � Foundation k � p rN Line Total length/size— LEA HING ength/size LEACHING LINE ❑ No. & Length of lines pro Line / � 'h 4 FILTER BED X Distance to nearest: Well Foundation Pertl+ " Number Size ' SEEPAGE PITS ❑ Depth Foundation Property Line SUPS i ❑ Distance to nearest: Well v , DIS OSAL PONDS ❑ 'I I hersby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Iounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the following: "I certify,that in the performance o!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 Gal'ffornia."Contractors hiring or sub contracting signature following- tion ! f .p f....T...-..�-f...........:sas- certifies the person 1 certify that-in the performance of the work for which this permit is issued,I shall;mWPTQ persons subject to workman s compansa tion laws of California". The applicant mus call for all:required inspections. Complete drawing on reverse side! r — Title: te. Signed FOR DEP RT MENMUSE ONLY t � �► w 07 Date 'Z Area Apr lication Accepted by 1-7 ' Finllk4s action-by 1 Date Pit for Grout Inspection byDate ,.t.i�� "•° " Additional Comments: � k``� ' ❑ Stk 466-6781 ❑ Lodi 31 9 3621 ❑ Manteca 82:i=7104:1 p'Tz4ltaGY 83�e., p. Applicant- Return all copies"to:'E nvinorimerital Health Permit7Seniices 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201" ' £ FEE AMOUNT DUE" AMOUNT REMITTED CASCK;H RECEIVED BY ! MIV INFO + EH 13-24(REV.101831 L-i 57- EH 10-28 r