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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 1 YEAR FROM DATE ISSUED L - ., ... (Complete in Triplicate). .= 1{I{ 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. I t , } - , �. +Y, t4. ;' - I ;� "4C +- 0 �7'ii O�ot Si4 ze PM 'City Job Address j { Li GO w!/A '��Address �` �6 ti `T`� Phone Owner's Name C7 �__ ` �Ult —Address .Qr � y •�O_ � License I�or•?'S hone Contractor_ i TYPE OF WELL/ `+� ^NEW WELL E3 TYPE REPLACEMENT ❑ DESTRUCTION LJ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISPOSAL FLD. __ -'PROP. LINE DISTANCE,.T,�NEAREST: SEPTIC TANK _ SEWER LINES -- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ©-Open Bottom �`' �❑ Manteca Dia. of Well Excavation _- ❑,Domestic/Private - - Q Gravel Pack �❑ T�acy `� Type of Casing =_ Specifications { ❑ Public 6 Oiher_ ❑,Delta ..\ Depth of Grout Seal Type of Grout p by- El r' ' r�r' pprox. Depth `❑ Eastern` •Surface Seal Installed by- - IIF _ 1 7:�� H+P, _ State Work Done —_ Repair Work Done ❑ Type oYPump - , Well Destruction :❑ Well Diameter -� �a 8ealinT_Material (top 501 — Depth *- 1/X "r '"f Filler`Material (Below 50") - I E TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will-serve: _Residence -Commercial_. Other %Number of-living units: � Number of bedrooms_W_a_40� AA Character of soil to-ajdepth of 3 feet: ,4_A240 �" � .Water table depth }SEPTIC TANK �Ij E] Type/Mfg _ �i.�ji Capatityl -(:L No. Compartments PKG. TREATMENT PLT. �, rMethod of Disposal Elj�.cT � f { i Distance to nearest: Well� Foundation Ape1�- Prop\JLine-�S I LEACHING LINE O No. & Length of lines. ' Total length/size_ ;`FILTER BED ❑ '..Distance to nearest: Well�[12_ Foundation� ��operty Line` T c Size Number ,,SEEPAGE PITS � ❑ Depth I is SUMPS +� ❑ Distance to nearest Well Foundation Property:lir('S �,DISPOSAL PONDS I ❑ 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, an rules and regulations of the San Joaquin-Local Health,District-,'A k�', 1; .) s\ t 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, (shall-nc t ubjeet to�workmaft's compensation laws of California."" Contractor's hiring or sub-contracting signatui employ any person in such manner as to become s certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to work tion laws of California."l, 1 I � The applicant must call,for all}eq ed ins ctrons�Cmplete drawing�on�reverse�side. � � 4 j } -se�ew�" ` _ Date { Signed X ! Title: _'�,t - )7 i FOR DEPARTMENT USE ONLY Date i r ,. Area f — Application Accepted by tt \ Pit or Grout Inspection by _ — Date i 1\Flnsl>Inpe�tion by Date �1 Additional Comments: _ + t [J Stk 466-6781 [i Lodi 363-3621 O 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 _ _ . _ r CK. RECEIVED BY6"*-—'DATE'_ PERMIT NO. AMOUNT-OUE -AMOUNT REMITTED"" CASH .: INFO I-�+ EH 133N.IREV_Iza,57 EN W26