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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inutaa the work herein dMafbed• his� s made in compliance with San Joaquin County Ordinance No.549 for sewage a No.1882 for wall/pump and the Rulea and Regulations'at Son jossiuln Local Health District. Job Address � 'at �! J z✓ A F Q•=-2 City Lot Sin !/2 PM Owner's Name p f ' r'i- Address e — PhaM Contractor / L�-L --Address �� l�f ,0 r,4 License No.92:ZZ. Ph,b 4J TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION U Tom, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C, Industrial ❑ Open Bottom ❑ Manteca Dim., ./ell Excavation Die.of W91 Cm" C; Domestic/Private ❑ Gravel Pack Tracy Type of „ing Spedricatforts C' Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation _ Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump M.P. State Work Dona Well Destruction ❑ Well Diameter Sealing Material(top 50 Depth Filter Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION U Ileo seprie�systimhd M fes' Is awileble tM� het.) Installation will serve: Residence_4,*' Commercial_ Other Number of living units: .__ Number of bedrooms ,, Character of soil to a depth of 3 feet: :�;eqWPV —Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.CornPW Wft PKG. TREATMENT PLT.i7 Method M DiapooM Distance to nearest Wait_ Foundation Prey Lina A FT Total length/size LEACHING LINE No. 8 Length of lines 7-' r FILTER BED ❑ Distance to nearest: Well _X6�Fourdation,ST/"T- Property Line S F SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well. Foundation Property Lles DISPOSAL PONDS r-' I hcreby certify that I have prepared this application and that the work will be done in aeCadonen with San Joaquin County OWWWOCaa,8 1 MW rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that In the performance of ter M I ahaM ftOt work for which this permit employ any person In such manner as to become subject to workman's compensation tar"of California."Contractor's hkkkg or dignatum certifies the following:"I certify that In the performance of the work for which this permit is Issued.I"arrtpley psraona NA00010wor<rrtan'a tion laws of California." The applicant must call 15 r all requlrtd inspections. Complete drawing on►everts side. Signed K_ - "� -- Title: __"o Data: _, c OR DEPARTMENT USE ONLY O� ��} ' Application A:cepted by Data Am3 2�o�J Pit or Grout Inspection by Date Final Inspaetfon by Date e7 Additional Comments: _ C'. Stk 408.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 8366386 Applicant • Return 111 Copies to: Environmental Health Permit/Services 1801 E. Hal~Ave.,P.O. Box 2008, Stk.,CA 88201 FEE MOUNT DUE AMOUNT REMITTED LA a SH RECEIVED BY DATE ►ERMIT'IVO. INFO /-� . EH 1114 IetV i A,.i EH 1!26 ,