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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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. . _i; 0 ) PM Job Address City Lot Size Owner's Name l ._t/4� Cv Z ` t'L Address Phone i 1 f � 9 Address icense No. Phone Contractor. i RD TYPE OF WELL/PUMP: NEW WELL ❑ $. WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑$ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 w ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 17 Delta Depth of Grout Seal Type of Grout I I irrigation _:Approx. Depth I I Eastern f. Surface Seal Installed by - Repair Work Done ❑ Type of Pump A P H.P. State Work Done Well Destruction ❑ Well Diameter 11 Sealing Material (top 501 Depth I { Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION i 1'.REPAIWADDITION l I DESTRUCTION t aseptic system permitted it public sewer is available within 200 feet.) Installation will serve: ResidenceC mmercial ether Number of living units: ___4 Number of�drooms i Character of soil to a ept of 3 feet: Water table depth SEPTIC TANK TypelMfg -� Capacity No. Compartments PKC. TREATMENT PL . ❑ t Method of Disposal Distance to newest "" I+Ve11' FiiundatiSn Property.Line LEACHING LINE ❑ No- &Length of lines 4 Total length/size FILTER BED EJ Distance to nearest: Well Foundation-__ �� Property line- SEEPAGE PITS l 1 Depth Size ! Number SUMPS Ll Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ I 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 rules and regulations of the San Joaquin Local.Health-District-��—::�--�.a.—..�- 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 employ any person in such manner as to become subject to workman's compensation laws-of-California=-GontractoYs 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 a f Californ' 1 i The applican t It f r all r ulre ns c'ons. Complete drawing on revers . ° Date: Title: l__ F Signe © FOR DEPARTMENT USE ONLY Application Accepted byDate U + Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: -+ �"`^r""�'' + J" ❑ Stk 466-6781 ❑ Lodi •369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 — —"--EEE IMOUNT-REMEO • RECEIVDBY —i5AE RPEMiT,NO NF � l " CASH ' r ' , f.EH13- {q EV, EH 14-26M t