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:- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f= 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209)'466-6781 «., PERMIT EXPIRES 1'YEAR FROM DATE ISSUED Mc'7wc� (Complete in Triplicate) Amade in compliance pplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, Local Health District.with San aoaquin County ordinance No.549 for sewage or No. 186'1 for well/pump and the Rules and Regulations of the San J p p This SPPI ant tion n � Joaquin Job Address T� _ City C NLot Size !�� PM Owner's Name W1 , ,i� j��Lk ,. AddressF-� �� �.{y7:M�. Phone Contractor II� Address TYPE OF WELL/PUMP: License No- Phone NEW WELL ❑ WELL REPLACEMENT Li DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK Y OTHER ❑ SEWER LINES _� DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP. LINE INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTI ❑ ON SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca ❑ Domestic/Private ❑ Gravel Pk Dia. of Well Excavation Pack ❑ TDia. of Well Casing ❑ Public racy Type of Casing r, ❑ Other ❑ Delta fr Specifications ❑ Irrigation Depth of Grout Seal T --Approx. Depth ❑ Eastern! f Type of Grout Repair Work Done ❑ T Surface'Seal Installed by Type'of Pump H.P. Well Destruction ❑ Well DiameterV" Sealing Material (top 50') State Work Done DeptFil —.=-Filler Material (Below 501 TYPE OF.SEPTIC WORK: NEIN INSTALLATION ❑ - REPAIR/ADDITION ; ❑ DESTRUCTl4N (No septic system permitted if public sewer is I� Installation Wil serve: Residence_ Commercial— Other available within 200 feet.} Number of living units: �N Number of bedrooms Character of soil to a depth of 3 feet: r SEPTIC TANK �' ' x Water table depth TVPe/Mfg Capacity -� PKG. TREATMENT PLT. EJ 11 t No. Compartments Distance to nearest; Well Method of Disposal j Foundation property Line LEACHING LINE Q 1` r ,❑ No. & Length of lie � �FILTER BED X' tan- 6 Total length/size ❑ Disi�nce to nearest Well Foundation 1 I 1 Property Line SEEPAGE PITS — `B Depth Size SUMPS ❑ Distance to nearest:. Well Number DISPOSAL PONDS © Foundation Property Line I hereby certify that I have prepared this application and that the work willbe done tri accordance with San Joaquin county ordinances, state laws and rules and regulations of the San Joaquin Local Health District. a Home owner or licensed agent's si nature certifies the following: "I 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."Contractor's hiring or sub-contracting signature certifies the following:"!certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's com tion laws of California." = pensa- The applicant must call for all r wired ins .+ �i r inspections. Complete drawing on reverse side. x Signed Title: bate: I rt' FOR DEPARTMENT USE ONLY Application Accepted by # I� Date — Area f Pit or Grout inspection Date.— Final Inspectiori by j Sr'� T— Date r Additional Comments: - 4 ❑ Stk 466-6781 C1 Lodi 369-3621 �: ❑ Manteca 823--7104 ❑ Tracy 83x6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO , RECEIVED BY PATE PERMIT''No. i +;EH 1324 IREV. a 57 ZL'^". I� "� EH 14-26 a-7