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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) ' Application is-hereby made to the San Joaquin Local Health District for a permit to construct anWor 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. y Lot Size `te PM � Cit . Job Address t w - - , Phone Owner's Name. Address 5U i�,so L y31v 2f3o310 �SZ g�1 �� CS'7- Phone" >JC� Address � �� •�•� License fyo._�—� Contractors-- �T� — DESTRUCTION ❑ NEW WELL^ WELL REPLACEMENT ❑ 4 Mou�cx,06 V>� TYPE OF WELL/ :-. � SYSTEM REPAIR D OTHER PUMP INSTALLATION ❑ ,. -�..�..�..:o..,.� `SEWER LINES �-- DISPOSAL FL D. PROP-LINE" DISTANCE TO NEAREST: SEPTIC TAMC, OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS`� Dia. of Well Casing 2 laL i ❑ Industrial [I Open Bottom 0 Manteca Dia. of We} Excavation Specifications Gravel Pack ❑ Tracy Type of Casing @ lPrivate " +' �b Type of Grout T � Cl Oth�r n Delta Depth of Giout Seal i7 Public rl Surface seal installed by �c ,YS' �:�2ltt I Irfigation t ,, �SC7Approx. Depth I 1 Eastern ai-"� State Work Done �] H.P. Repair Work Done Ll Type of Pump Sealing Material ftop-50 Well Destruction ❑ Well Diameter Filler Material I8elow"50'1 Depth ^` TYPE OF SEPTIC WORK:ANEW INSTALLATION l 1 REPAIR/ADDITION l i �S 11:1 ON l I avlailablesept1w thisysn 200 fe permitted it public sewer is v i Installation will serve:` Residence Commercial Other [ A 1.3�.Number of living units 'Number of bedrooms Water table depth 1 Character of soil to a depth of 3 feet: Capacity�.=— No'Compartments• ^"'� SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG, TREATMENT PLT. 0 e Foundati.n ' Property Line Dist 9 ance to nearest: Well 4 V * F 4 W4 Total length/size t 1# LEACHING LINE -J i.❑4 1 No. & Length of lines �.- Foundation Property Line FILTER BED f ❑ Distance to nearest: Well . .a►� . �. Size Number SEEPAGE PITS I I Depth ` property.`Line 4 SUMPS. ❑ Distance to nearest: Well Foundation . q DISPOSAL'PONDSt �1 I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquincountyordi Lances, state laws, and rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit ring or o issued, I signature shall not employ any person in such.manner as to become subject to workman's compensation laws of California-" Contractor's nsrsub'ect t worktrant1scompensa- certifies the followings"1 certify that in the perjormance of the a k r which_this parfnit is iss d,l shall employ p tion laws of California." �s/ �"�1 ,'rit The applicant must call for all require ' spections. Complete drawing on reverse side. Title: _ _ Date: eo Signed"X r7'FOR PARTMENT USE ONLY '2-0Z0 t/f Date Area i Application Accepted by f,-3_- 0 Finali,qnspection by Date Date s—�-- Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Re urn ail copies to: En vir nmentald40alth Permit Services 160 Hazes nn A P.O. ox 2009 Stk , CA 95201 F FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT No. INFO + EH 13-24{REV.1 95) EH 14.26 f/