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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA . Telephone (209) 466-6781 ERMIT 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. Job Address L 2 City G Lot Size 2 <,- PM Owner's Name e, Address � I Phone Contractor's Name +'Lr License No. TYPE OF WELL/PUMP: Phone EW:WELL C WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER C DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD._____ PROP. LINE FOUNDATION AGRICULTURE WELL _- OTHER WELL PITS/SUMPS -INTENDED'USE�^ TYPE-OF-WEL1--`-FROBLEMARE9;"-CONSTAUCTJON-SP_ECIFICAT!ONS ❑ Industrial ❑ Open Bottom 0-Manteca 'r Dia, of Welt Excavation ❑ Domestic/Private ❑ Gravel Pack' El Tracy Type of Well Casing 1:1 Public ❑ Others of Casing Specifications ElDelta Depth of Grout Seal Type of Grout O Irrigation _Approx. Depth C Eastern } Surface Seal Installed by f Repair Work Done C Type of Pump N:P. rT ` State Work Done Q Well Destruction F] Well � Materia E ell Qia ,.eter Sealing �itop 60;J,, Depth__ I Filler Matefial tRplow 50'), TYPE OF SEPTIC WORK: NEW tNSTALLATJON C REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted Ff public sewer is ��•++ t Installation available within-25b feet.) Installation w 11 Serve: Residence Commercial_ Other Number of living units:-/-- Number bf: e ooms ~ Character of soil to a depth of-3 SEPTIC TANK 1-1 Type/Mfg l -- Water table tle. _ TREATMENT PLT. ❑ r1 CJC9 O _ Capacity partm No. Coments PKG. _ s � �s p, ' Method .if islwsal �C Distance to nearest: WA-* 4Fo6ndation t ..- Property Line F � I LEACHING LINE j} Nc & CerigtW;o -fines y=~ " r� FILTER BED Total length/size D Distance to nearest: WellFoundation f Property t ._ SEEPAGE-PITS... ter .-DeFnh".'=P-5 - Size— L-f SUMPS Number _ G Distance to nearest: Well��FoundaUon Pro DISPOSAL PONDS p I party Line •1 herebycertify prepared pp rtify that I have re red 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 the performance of the work for wh(ch this permit is issiked, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature tioncertifies the following:"I certify that in the performance of the work for which this permit is issued,E shall employ persons subject w workman's compensa- tion 1 tion laws of California." F The applicant t call for all r uir in 1 eq spe ns. Complete drawing on reverse si Signed > --- Title: r1. tti Date: } FOR DEPARTMENT USE ONLY Application Accepted b G}�� / P Y / / Date� Area Pit Grout Inspection by r + � � Final Inspection by Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 Ft ❑ Manteca 823-7104 ❑ Tracy 835-MW - -)plicant-Return all.copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 7- FEE AMOUNT DUE AMOUNT REMITTED CK# INFO CASH RECEIVED BY DATE PERMIT NO. 04;¢�JRA.10/83)