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APPLICATION FOR PERMIT Y SAN JOAQUIN LOCAL HEALTH DISTRIi;f 1601 E. HAZEL T ON AVE., STOCKTON, CA FTelephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) l 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. 10 Job Address c/ `V. lLr Ci Lot Siz PM l Owner's Na Address Phone F r r + � t -V Contrac o Address � Li'ense No. zj Z Phone S� TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. " PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications G ('l Public Fl Other Cl Delta Depth of Grout Seal Type of Grout [ , F1 I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ "\ Repair Work Done ❑ Type of Pump H:P. State Work.Done Well Destruction ❑ Well Diameter. Seating Material (top 501 Depth Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EP ADDITIO DESTRUCTION I I (No septic system.permitted if public sewer is " available within 200 feet-) Installation will serve: Resence Commercial Other Number of living units: Number ar&rnitimV. Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length.of lines Total length/siz AV X FILTER BED ❑ Distance to nearest: WeIIPro Q Foundation 1 D party Line !!S-- _ i tD6-� 177 SEEPAGE PITS - I I Depth Size Number 4 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 1 rules and regulations of the San Joaquin Local Health Di%trict. { 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, I shall not .i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 ifomia." The applicant u call for r uira inspections. Complete drawing on rever s.,e q Signed Title: ._ reveres., C f Date: r I .. Fl FOR DEPARTMENT USE ONLY .. Application Accepted by �� Date �]� Area 3 j Pit or Grout,Inspection by Date Final Inspection bye._ VVI;S <:D Date j' rAdditio$1 Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant - Return all copies to: Environmental Health Permit/Servi 1601 E. Hazelton Ave., P.O. Box 2W9, Stk., CA 95201 F FEELAMOUINT DU I AMOUNT REMITTEDggRECEIVED BY DATE PERMIT N0. INFO EH 1324 tREV.i/K5) p I'�z, --pi I R I --DIGS l F EH 14-28 C.