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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 ;,.rr,,• r •• • �; r r,.� -, .y, •, ,� 1 .(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 made in compliance with San Joaquin County Ordinance No.549 for sewage.or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f..RVAt. Hyl . Job Add ssre ` 1 _____ ��_T_ City�� Lot Sire �M Owner's Name 717.. Address MOP,' Phone ' Contractor Addr �' ess �•� -�"� ", _ icense-.:Nor. ��. � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES m FDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ----INTENDED-USE YP£OF-WELL. PROBL-EII WREA4„ CON TR i A_ 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Back ❑ Tracy Type of Casing_ _ _ • Specifications 13 Public ❑ Other ❑ Delta Depth of Grout Seal ; Type of'Grout p• ❑ Irrigation ��pFgx. Depth © Eastem Surface Seal lnstalldd'by' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material Itop 50') Depth—' .1 "F Filler Material(Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION O INo septic system permitted if public sewer is i available'within 200 fr}et.) Installation will serve: Residence_ Commercial her Number of living units: Number of rooms i 1 i Character of soil to a depth of 3 Leet: 0 { Water table depth SEPTIC TANK i D--TYpe/Mfg Mtat Capacity_ M No. Compartments PKG. TREATMENT PLT.❑, * Method of Disposal Distance to nearest: Well foundation - Property Line LEACHING LINE 8�Wo. & Length of lines To ral • length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line I I lr SEEPAGE PITS ❑ Depth - ' i �i 1 Number '•-' SUMPS G/Vstance to nabrest: Faun ati . Property Li 1 DISPOSAL PONDS ❑ ► A I hereby certify that I have prepared this application and that the work will be-done in accordance wid San Joaquin countyardin antes state laws and r rules and regulations of the San Joaquin Local Health District t -' -..-,t/`. . •- Home owner or fcaroea agent's signature certifies the following: "I cartify:that in the performance of•the worklor.which this permit is issued,I shall not employ any person in auch manner as to become subject to workman's compensatiortlaw"fXalifomia:Z!Coi(tr tufa hiring or sub contracting signature tertif les the fdlowing:"I certify that in the performance of the work for which this perrnit is issued,I shall employ-persons subject to workman's compensa- tion 1 f California."• I The applicant Just call for I =imdt' ns.Implete drawing on i arse si ` i Signed Title: Date_.' ll FOR DEPARTMENT USE ONLY K r SI Application Accepted by Data Area (1, � Pit or Grout Inspection by Date^ rFinel Inspection b r �JRAMA AdEityonlil Comments: - L i �_ 'f•.,s� �f If Stk 468-6781 , ❑ Lodi 3W3621 ❑ Manteca 823-7104 ❑ Tracy 8354MM -z-APpli atttlE- Return all copies to: Environmental Health Permit/Services.1801 E. Haaelton Ave., P-0. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT RFmrrTED"� 'k, f RECEIVED BY DATE PERMIT'No• , +EH 13-241REV.ries! i