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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL-HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR`FROM DATE ISSUED (Complete in Triplicate)" Application is hot aby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described:This application is i 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 Districts. Job Address F MA A City fn n7ek of Size _._:, PM Owner's`Name Address Phone s""J - mar•_,•„-.� � k Contractoi� Address- ; License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ -WELL REPLACEMENT]❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR!❑ __—OTHER L] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ( DISPOSAL FIk:D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER-WEL-L-.-"p'a't PITS/SUMPS Iy—INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOj4S' ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excalation ,; Dia' of Well Casing F ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing tom:.-Ct 11t' Specifications f I f'�u is iii Other CI Delta Depth of Grout SealR Type of Grout _. I I Irrigation _Approx. Depth _ I I Eastern ,,Surface Saa! Installed by Repaie,Work Done ❑ Type of Pump H.P. 1 ` S rjStat6rork Done j t Well Destruction ❑ Well Diameter Sealing Material [top 50') �1 Depth Filler_MateraaLLB `L'v I TYPE 0TH SEPTICSWORK: NEW INSTALLATION I I REPAIR/ADDITIO ESTRUCTION I I {No septic system permitted if public sewer is z ! available within 200 feet.I Installation will serve: Residence Commercial_ Other * Number of living units: Number of bedrooms r " Character of soil to a depth of 3 feet Water_i able depth SEPTIC TANK ❑ Type/Mfg Capacity sNll Compartments PKG. TREATMENT PLT. O { -v,Method;of Disposal Distance to nearest: Well Foundation Property Lirie .' I . : t : :t5�;. r•. . I LEACHING LINE ❑ No..& Length of lines Tg;al length/size i ) FILTFRrBED istance Ito nearest: Well f Faundatian-- P opertyrLme.' SEEPAGE PITS I I I Depth' Size \.Number 3 ; It, SUMPS ; ❑ Distance to nearest: Well Foundation 1 fPropertyjLirle ! _l DISPO AL POND$ ❑ I hereby-,-fortify that I have prepared this application and that the work will be done in accordance with"San Joaquin conly oidinlnces, state laws, and rules antt'fegulations of the San Joaquin Local Health Di1trict. 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, I shall not t t--.empto_y_-any person in such manner as to become subject to workman's compensation laws of California-"Contractor's hiiing or sulci-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons hubject to workman's compensa- tion laws of lifornia." I The applica t "ust c II for all equired ins /ction'. Complete drawing on reverse side. I Signe Title: Date: F EPART T USE ONLY Application Accepted by Date Area t / Pit or Grout Inspection by Date Final Inspection b Dat Additional Comments: _ "_ A ❑ Stk 466-6781 ❑ Lodi 369-3621-..,..,._.❑YAAanteoe-„8237104..__ _l].•Traey�8356385 _- ._._ .� -M- .�-. - - - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E..Hazalton Ave., P.O. Box 2009, Stk., CA 95201FEE y i INFO AMOUNT DUE AMOUNT REMITTED CA8 RECEIVED By DATE PERMIT IVO. +..EH 1324 IREV.i/n 5) EH 1/-28 . - r