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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 iComplete in Triplicate) Application Is hereby made to the Sen 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, 14162 for well/Dump and the Rules and Regulatiom of the San Joaquin Local Health District, _ _ Jab Address G` Q ��.—� City of site PM Owner's Name __Zzf &L2�_ Address �'—''Yr—� Phone Contractor's Name _ en.No. - _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cr SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ___— SEWER LINES DISPOSAL FLD..__ PROP. LINE FOUNDATION AGRICULTURE WELL .___. OTHER WELL___ PITS/SUMPS ..h INTENDED UOE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x ❑ IndustrialestLI open Bottom ❑ Manteca Dia.of Well Excavation -- Dia.of Wall Casing ❑ Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public 1I Other ❑ Della Depth of Grout Seal Type o1 Grout ❑Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by--- Repair y Repair Work Donn ❑ Type of Pump _-- H.P. ..— State Work Done Well Destruction ❑ Well Diameter Sealing Material flop 50'1 N Depth I lariat(Below 501 — W TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPPAR/ ITION DESTRUCTION❑ available INO lw thin 2DO feet I mmit J A public sewer Is Installation will serve: Residence v Commercial_ Other 1 Number of'IlvinB 6,0? f/ Nufnbar of !adrooms— — Water table depth — Character o1 soil to a depth of 3 fele_. No. Compartments __C:7SEPTIC TANK ❑ Type/Mfg --- Capacity 1 Method o1 Disposal PKG. TMATMENT PLT.❑ 1 y �--"DTM?rcce to nearest: Well Foundation__ Property line •'� ' LEACHING LINE d '. l!,Length of knee Total length/ctzn li ';Nol FILTER SED "❑ Distance to nearest: Well Foundation._.—_ Property line ❑ Depth _ SEEPAGE PITS Wall SUMPS � Distance to nearest: Wall�-(-/lam_ Foundation Property Line L _ — _�. __— DISPOSAL PONDS ❑ - WI' I hereby cartiH that I have prepared this application and that the work will be done in orcordonce with San Joaquin county ordinances,eters laws, and rules and regulations of the San Joaquin Local Health District. pp I shall net Home owner or lice agent's signature certifies the following:"I certify that in the performance of the work for which this Permit is issued, employ any person in such manner ee to became subject to workman's compensation laws of California."Conlracm�s'lsubject b act to workmang or Rseompense- '.� certifies the following:"I certify-that In the performance of the work for which this Permit is issued.I shall employ pc 1 tion laws of CalKomle." ids TheedpWitan[mus?Sell II regpuad in tions.Com at rowing on r s Signe ` r �'/rHY�_/Y/``/ Title: / Date: FOR DEPARTMENT USE ONLY p Ai-- O V_�- 814 Area O }. Pit or Grout Accepted by —n..�.0+ • Jia 4=.Le _ Date_ —c� Dern Final Inspection by /y�p,.. k� Dern_r15�y Pit or Grom Inspection by ? Additional Comments: e ❑Slk 466-Ml ❑ Lodi 369.3621 ❑ Manteca 913-7104 ❑Tracy 836.6395 nApplicant-Return all copies to: Environmental Health Permit/Services 1601 E.Hazelton AVG., P.O. Box 2009, Stk.,CA 95201 FEE a RECEIVED BY DATE PEflMR'NO. 4 INFO AMOUNT DUE _ AMOUNT REMITTED CA511 _ .EH 6•N IAEV.101611 /I� _)O�I V/ EH 1L]a �