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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Y 1 stall the work herein described.This application is Application is hereby made to the San Joaquin Local Health District for a permit toconstructand/or inI made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1562 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. 011 4 City 7 � y Lot Size wf PM Job Address a /J'!X-7 7 �OI�T Address � C Phone i ow Owner's Name —1�— `` 1�,40Y I 3 Z8C0�1 Phone`��Jl�g Address A � *L-+cense No. Contractor/ `� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ INSTALLATION ❑ ' `_.� OTHER.[J SYSTEM REPAtRW❑ PUMP IN t �.. �- - ----- DISPOSAL FLD. PROP. LINE I DISTANCE TO NEAREST: SEPTIC TANKI SEWER LINES FOUNDATION{ AGRICULTURE WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing I El Industrial ❑ Open Bottom ❑ Manteca,. .•,.Dia�of-WellaExcavation.. 1 t" Specifications ❑ Tracy Type of Casing EJ Domestic/Private.❑ Gravel Pack [ Type of Grout ' 13 Public i ❑ Other El Delta Depth of Grout Seal t ---Approx. Djepth ❑ Surface Seal Installed by Eastern F] Irrigation SPP ,State Work Done Repair Work Done ❑ Type of Pump H.P. -` .4 4 : p a Well Destruction Ll Well Diameter Y.-Sealing_Material It`op.5d'j---- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITION ❑ DESTRUCTION ❑ jNo septic system permitted if public sewer is ti r i available within 200 feet.! Installation will serve- Residence `Commercial_ Dther vin units: Number of bedrooms -- --�- --- i Number of Ii g, Water table depth Character of soil to a depth of 3 feet: No. Compartments n) SEPTIC TANK, ❑ Type/Mfg # Capacity 4 #f. Method of Disposal PKG. TREATMENT�PLT. ❑ ut Property Line j Distance to nearest: Well Foundation P Y r - Total-length-/size LEACHING LINE-- ❑ No. & Length of lines 1. ' '`, Property Line FILTER BED ' ❑ Distance to nearest: Well Foundation, Number-j/t SEEPAGE PITS El /,!Depth g sizeA,Q E�= Property Line f SUMPS s ❑ Distance to.nearest: Well '"� Foundation• DISPOSAL PONDS; ❑ �i� I hereby certify thaf I have prepared this application and'tFiat'ttie woYk+niill'tSe done in accb�dance'witFi San Joaquin county ordinances, state laws, and rules and regulations of the San JoaquinL`bcal Health District. s Home owner or licensed agent's signature certifies the following: "l 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 contfacting 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 Californi t ZI ,F The applicant mus. fired i oris. Co mplete drawing on reverse side. ik -r�t/�Oa ' Date: 'Signed Title: 3 j OR DEPA USE ONLY � � � f Application Accepted by - _ ._ ' Date Area t * Date H k ' Date Final Inspection by Pit or Grout Inspection by t l Additional Comments: ❑ Stk 466-67$1 Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 'Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009,Stk., CA 5201 --r FEE CK RECEIVED BY ' DATE PERMIT"N0. INFO AMOUNT DUE AMOUNT REMITTED CASH. t q y N. VIN + EH 1324(REV.t/e 51 .}��` "" EH 14-26