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APPLICATIONr.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. Ld/ Job Address t-5enl �✓ 4 City � '� Lot Size PM -�-�Z i ��-fix'-� �1` - $r�P�.J Phone Owner's Name Address Contractor s lrlcro�- Address Al, 4270 r License No. q/ _T -74 Phone 9�� } TYPE OF WELL/PUMP: �z-N.EW-WELL_Q - R WELL REPLACEMENT Ll DESTRUCTION PUMP INSTALLATION F-1SYSREPAIR L] OTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK S ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS _ L1 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation """— Dia.. ofWell Casing t ingons il„ El Domestic/Private ❑ Gravel Pack El Tr Type o as � Specifications F] Public ❑ Other Delta Depth of ut Seal Type of Grout - I I irrigation Approx pth l l Eastern Surface Seal l ailed by Repair Work Done El Type ump H.P. State Work Done _ I Well Destruction ❑ ell Diameter Sealing Material Itop 50'1 Depth Filler Material)Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION is REPAIR/ADDITION DESTRUCTION I 1 1No septic system permitted if public sewer is 9J F available within 200 feet.) IW.) Installation will serve: Residence e Commercial .= Other ; Number of living units: Number of bedroom�, `J lf� Character of soil to a depth of 3 feet: C r Water table depth SEPTIC TANK ❑ Type/Mfg _� r Y�'T�� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal xDistanceI--*' st: Well Foundation t Property Line , P J" LEACHING UNE No. & Length of lines +�' � Total length/size ,Nf FILTER BED ❑ Distance to nearest: well Property Line SEEPAGE PITS l Depth �'j`f Size ii Number SUMPS. L1_ Distance to nearest: Well /-6-0/ Foundation �r Property Line �O DISPOSAL PONDS y (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 "ules and regulations of the San Jbaquin_Local Health Di';trict. — 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 r 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: "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 California." f The applicant must call for ail required inspections. Complete drawing on reverse side. E c3' �!' t "''Title: Date: Signed Xee i FOR DEPARTMENT USE ONLY Date Area Application Accepted by l � , Pit or Grout Inspection by Date 6 Final Inspection by data 9 I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 - Y f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95281.' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVELIF, D BY DATE PERMIT NO. + INFO �( Q i r�EH13-24IREV.t/H51 U EH 14-28