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i v ~ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 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 d scribed. This application is made in compliance with SarilJoaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ( �/[ /`' T___,�� `Sl City �C ��1,ot Size PM Owner's NameVUs ddress Phone �I. Contractor ; /_0r_1IAddress License No. Phone TYPE OF WELL/PUMP: ,t" N�"' _ NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUC aw–er + PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0 , 41. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , ^-FOUNDATION-- AGRICULTU LL OTHER WELL PITS/SUMPS f �, INTENDED USE iTYPE OF WELL PROBL EA CONSTRUCTION SPECIFICATIONS t ❑ Industrial © Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing l i ❑ Domestic/Private Di Gravel Pac ❑ Tracy Type of Casing Specifications N ` r f'] Public Cll,Ot Cl Delta Depth of Grout Sea! Type of Grout r f I I Irrigation r._Approx. Depth I i Eastern Surface Seal Installed by I Repair Work Don Type of Pump H.P. - State Work Done— ' :F Well Desir on ❑ Well Diameter Sealing Material (top 501 Depth Filler Material Welow 501 dq TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l I. DESTRUCTION { o septic system permitted if public sewer is P �� ra ;L F available within 200 feet.) , Installation will serve: Residence— Commercial— Other, r y Number of living units: �! Number of bedrooms t i Character of soil to a depth of 3 feet: i Water table depth # LV SEPTIC TANK ❑IType/Mfg Capacity "No. Compartments I PKG. TREATMENT PLT. ❑ I Alethod-of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑' .No. & Length of lines . Total length/size i FILTER BED ❑: Distance to nearest: Well Foundation Property Line & - t I SEEPAGE PITS I i .Depth Size Number SUMPS ❑'. 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I 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 rules and regulations of the San Joaquin Local Health District. 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 an ` employy person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature F 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." 'll The applicant must call for ! require s ctio mplete drawing on reverse side. �1 Signed X. I 11r 9 Title: ��- (.�_ �'`A'` pate: �'� F DEPARTMENT USE ONLY Application Accepted by I Date ''LI Area Pit or Grout Inspection by 'II Date Final Inspection by page Additional Comments: I� i ❑ Stk 466-6781 ❑ Lo`di 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies,€o:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1. INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE AERMIT"N0. fc 71;5 IEH t3241gfV.riK51 �4'f� -- —& F2 H to-26 ✓ CEJ_ LJl/Li 6 I J 4 I�.