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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED i'' 4 "(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 3 made H compliance with San Joaquin County Ordinance No.5419 for sewage or No. 1862 for well/Pump and the Rules and Regulations of the Sa Permit to construct and/or install the work herein described. This application is Local Health District. e n Joaquin Job Address „ City I ° Lot Size ACrGES PM Owner's Name Address Contractor Phone � ' T—saDL✓��__Address P0. Ld�� 7•`a1 TYPE OF WELL/PUMP:License No,A& � Phone DEST NEW WELL ❑ WELL REPLACEMENT ❑ O PUMP INSTALLATION ❑ RUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ SYSTEM �"� � t p OTHER ❑ FOUNDATION , ISPOSAL FLD. PROP. LINE AGRICULTURE WELL --� INTENDED USE OTHER WELL PITS/SUMPS r TYPE OF WELL PROBLEM AREA r5- CONSTRUCTION,SPECIFICATIONS ❑ Industria! - ❑ Open Bottom ~- �. ❑ Domestic/Private �, ❑ Gravel Pack C1 Manteca Dia. of Wel! Excavation r 4► Dia, of Well Casing '�_ <�.Y ..❑ Tracy T g ❑'Publii; ••+�:" "• � ' �•. Type of Casing ❑ Other •' `. w ° .tet. ❑ Delta �; specifications IJ Irrigation -=AAPr R-"Depth O EI t m Depth of Grout Seal Type of Grout Repair Work�Done ❑ T r Surface Seil Installed by YPe of`Pump H P r ; Well Destruction ❑ Well C ; - State Work Done " DiameterSealing Materia! (top 50') p I `VL '`_ Filler�Material.(Below-50:1 si TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION p iDESTRUCTION {No septic system-peFmitted if public sewer is Installation will serve: Residence X 4 ! "**-available within 200 feet.) j Commercial Other 1 Number of living units:_L lk Number�of bedrooms _ Character of soil to a depth of 3 feet: Type/Mfg Water table depth SEPTIC TANK PKG. TREATMENT PLT. © ozc�l Capacity Q r - � E No. Compartments Z Method of Disposal Distance to nearest: Well/-DA2— Foundation Z O - Property Line LEACHING LINE ❑'; No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest.,. Well "L.N Foundation Property Line SEEPAGE PITS ❑ Depth SUMPS Size Number ❑ Distance to nearest: Well DISPOSAL PONDS ❑ Foundation Property Line 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: a work for employ any person in such manner as to become subject to workman's rcompensation laws oof Califonce rnia."Contractor's'h ringch 'or sub-contracting lsignaltnot ure certifies the following:"I certify that in the Performance of the work for which this permit is issued, l shall employ tion laws of California." p P Y persons subject to workman's compensa- The applicant must call for all required inspections. Co late drawing on reverse side. M� Signed - Title: Date: e29—04f_dQ FOR DEP T T USE ONLY Application Accepted by " Date' rea Pit or Grout Inspection by Date Final Inspection by r Additional Comments: Date ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 x Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n �,,�s x , FEE AMOUNT DUE CK r" `' INFO AMOUNT REMITTED EllCEIVED BYCASHDATE PERMIT'No, + EH 13-24{REV.t i e 5) � u EH 14-28 f�� EN X77