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S oP 2� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , .Y 1601 E. HAZELTON AVE., STOCKTON, CA ✓r Vr Telephone (209) 466-6781 ^ #{ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t L (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 descri r _ 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 L Local Health District. C C/� Job Address Ll 2_6_� U ' N � Cit `& Lot Size L PM LOwner's Name Address Phone r+ Yt o Y i�ddress J License No. Phone l Z ConUactor L TYPE OF WELL/PUMP NEW ELL [ILL REPLACEMENT El DE$TRUCTJON El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LII ES DISPOSAL F.l_�. } PROP. LINE FOUNDATION AGRICULT JRE WE L OTHER WELL PITA/SUMPS L } INTENDED USE TYPE OF WELL - PROBLEM AREA 'C - TRUCTION SPECIFICATIONS /�� C ❑ Industrial El Open BottomAllern hyT ❑ 'Dia. of Well Excavation DiyaQpo.� fCC/W/��e��S'f f ❑ Domestic/Private ❑ Gravel PackType of Casing SphE�ieate V p LPublic ❑ OtherDepth of Grout Seal TTZ 7JJY-- . I I Irrigation —Approx. DSurface Seal Installed by �7 UAYUIN OUNTY Repair Work Done ❑ Typeof Pump State Work Dne S Well Destruction ❑ Well Diameteraterial flop 50'1 FNVIRONMEATAL _�SIONyOepthrial (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATI0,41 REPAIR/ADDITION 1 I GEST)JUCTION I I (No septic system permitted it public sewer is dtrClfl A available 200 feet.l Installation will serve: Residence_ Co ercial her ' Number of living units: _ Number of 66drooms Character of soil to a depth of 3 feet: AWa)er tattle$gpth SEPTIC TANK ❑ Type/Mfg y Capacity M3TCo4ariments PKG. TREATMENT PLT_❑ _.. _ Methodof i al Distance to nearest: Well Foundation / jd_ Property Line r LEACHING LINE ❑ No. 8 Length of hales 1i V Alf [ I length/size i FILTER BED ❑ Distance to nearest: - Well Foundation JProperty Line v SEEPAGE PITS I 1 Depth Size u r Or SUMPS 1_1Distance to ne e$t: Well oundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 therformance of the work for which this pe permit is issued, I shall not employ any person in`soctr manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature 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." The applicant must II for all r� d ict_nspens. Complete drawing on reverse side. � � 6- — signed X Title: 6°�',M , `� Date: 2. FOR DEPARTMENT USE ONLY Application Accepted by \ �Z! fjti—� Date Z-- Area Pit or Grout Inspection by. Date Final Inspection by i Date Additional Comments: W — ❑ Stk 4668781 ❑ Lodi 369-3621 .[I Manteca 823-7100 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t. iFEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. `, 114 M(REV.VxW