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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone Q09) 466-6781 ` PERMIT EXPIRES TYEAR 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. (� ritV 4A Lot Size PM ID Job Address 4{ l / Phone Owner's Name Address 5 _ " License No, Phon� Contractor ddress TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARA CONSTRUCTION SPECIFICATIONS 1;1 ED Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - T e of Casin �-"` - Specifications:..__.,,.,. p-Domestic/Pii"vat`e�"'"'❑'Gfavel'Paek O-Tracy` = YP g `" Type of Grout ❑ public ❑ Other ❑ Delta Depth of Grout Seal YP i I I Irrigation �Approx.!Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Sealing Material {top ) i Well Destruction-^^� ❑ Well Diameter 9 i Depth Filler Material iBel TYPE'OF SEPTIC WORK: NEW INSTALLATION (Or REPAIRlADDITION I, pppESTRUCTION t 1INo septic system permitted if,public sewer is , aila8wi iri 200 feet:)' A Installation will serve: Residence Commercial Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth x Capacity J?_j6t0_ No. Compartments t r SEPTIC TANiC �}{''Type/Mfg § 'i F '� "f , ) Method of Disposal PKG, TREATMENT PLT.FI [ x ` t }}",Distance to nearest Well_19 u dation' l� Property.Line 16 Tot l I ngth/size LEACHING LINE ❑ No. & Length of lines d _ ^, t FILTER BED ❑ Distance to nearest: .Well Foundation-wProperty Line---, � � � 4 - � SEEPAGE PITS I I Depth - Size Number SUMPS ❑ Distance to nearest: We11 _-�-. Foundatiri [_� Property tine ` DISPOSAL PONDS ❑ - T that the workwill tie done in accordance with San Joaquin county ordinances, state laws, ander i hereby certify that I have prepared this application and rules and re'66iations of the San Joaquin Local Health Diltrict. 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 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,l shall employ persons su6ject.to workman's compensa a ` tion laws of CalifoPflia;', r -- - .i''fie Y. �i ns ctions. Complete drawing on reverse side. r The a � licant u�t call`for I required pe P � pp Signed X " / Title: -�� /i Date: Y /f FOR DEPARTMENT USE ONLY let #f DateE� Area ` f Application Accepted by + I J x rIII �Finl �c.i — Data i 0 Pit or Grout Inspection'by - Date /:/ onby Additional Comments: I ❑ Stk 966-6781 ❑ 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 95201 FEEAMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. i INFO f /4 + f- 0 i k+.EH13-24iREV.ItHE, rfl, i EH 14.28 t