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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED" j (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 o.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance N Local Health District. Lot Size PM Job Address ai0 i - Address = Phone O+ivni;r's Name _ Contractor ��j ddress v) .- License No '3�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ .� \ PUMP INSTALLAT ON ❑ t SYSTEM REPAIR-❑ OSI�E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ? FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL• PROBLEM AREA CON STRUCTION;SPECIFI CATIONS ❑ Ope" Dia. of Well Casing ❑ Industrial n ElOttom> Manteca' -Dia-df 11 Ex��avati ❑ Domestic/Private ❑ Ga_vel ack 'D Tracy Type of Casing Specifications (- F Type of Grout ❑ Public ❑ Other i❑ Delta IDepth of Grout Seal 14 ❑ Irrigation �pprox- Depth ❑ Eastern Surface Seal Installed by r _ - State Work Done 1 Repair Work Done [3H P Type of Pump 1 Well Destruction ❑ Well Diameter ! Sealing Material (top 50') { � ,f Filler Material (Below 50') k Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION P--MSTRUCTION ❑ (Nao ilabpe�c th n200 feetstOrn itted if public sewer is - \ - ID YY1 IS, r r� _ Installation will serve: Residence Commercial— Other �� s.. --- -x�- Number-ot living-units:- -Number of bedrooms - . y .� lid Water tabde le pth'/ # Character of soil to`a'ds_th of;3^feet:' - - ❑ T e/Mf ^I ' `� Capacity No. Compartments SEPTIC TANK' YP g Method of Disposal i. PKG.TREATMENT PLT. ❑ 4 Distance to nearest: Well _ Foundation_ =Plopertyline' —� LEACHING LINE . No-&.Length of lines t' ' Total length/size [I J I Line FILTER BED ❑ Distance to nearest: -We11 ( Foundation Property ( i _ - _ - •� SEEPAGE PITS. 6-'*-Depth Size ( Number SUMPS ❑ Distance to nearest: Well I ( Foundation Property Line = DISPOSAL PONDS ❑ �••- -_ ".`-"' `" __`..�.� �- ..�_-..�_.._-�---t-> -----^---"^.,.>•, __.. . 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-fhe following: "I certify that in the performance of the work for which this permit is issued, l 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 cert Pies 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- t i tion PaNr of Californi The applican must call or all requi d i cti n_s. Complete drawing on reverse sid 1 Title: Dater Signed ..�. ,,, � ,-.- � •-,�-��- ., ---- ,.:J 'tf '_`f/ _ FO .DEPARTMENT USE ONLY r j _••�,,.r� Date Area f Application Accepted by _�-^— Pit Grout Inspection by e_ g� ' v "Final'In;Pectiori by- Date J`�� Additional Comments: ' i k ❑ Stk 466-6781 ❑ Lodi�W-3&1I �� ❑.Manteca 823V104 ❑�Tracq'"835 6385 f Applicant Return all%eopies to: Environmental Health Permit/,Services 1607 E. Hazelton AJe.,,P,O. Box 2009, Stk., CA 95201 • ` f - e f "1. FEE AMOUNT DUE AMOUNT REMITTED;' RECEIVED BY DATE PERAAIT`NO. INFO .h EH 13-24 tkv.1/851V.�A v - 11 EH 14-28 r