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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 u (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heroin described. This application is made in compliance with San Joaquin Courtly Ordinance No. 548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ... Owner's Namo Contract TYP OF;WELLIPUMP: DISTANCE N A ES �f ..._ City a14VlK Lot Size ._ PM _ . Address A_An 1-!__& Phone k4r--1!A-s,9 Address i �t ).. License No.3-2b 226 Phone Za NEW WELL 0 O WELL REPLACEMENT U DESTRUCTION ❑ PUMP -I TALIATION-'LJ ,� w SYSTEM -REPAIR Cl OTHER 0 5ERTC TANK .'. — SEWER LINES DISPOSAL FLD.--_ PROP. LINE �F`OUNUATI_ '\� AGRICULTURE WELL OTHER WE_L_L_ PITS/SUMPS INTENDED USE '7yp.E 0`�`WELL 'PROBL A CONSTRUCTION SPECIFICAT -S_ _ IONS G Industrial %• 1 I U Open Bottom [ 1VManteca - ��_ fig Well Excavation r. Oia. of Well Casing L7 Dom stic/Private ❑Gravel Pack- • ❑ Trac *.`' ^►t,_r ,,, Yds T�pe of Casing_- Specifications f'I Public Ll Other n Delta Depth of Grout Seal Type of Grout ! I Irrigation _^.Aplxox.' Depth I I Easier[) Surface Seal Installed by� _ Repair Work Done 11 Type of Pump State Work pone Well Destruction Ll Well Diameter — Sealing Material (top 50') r Depth Filler Material (Below 50'i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitter) if public. sewer is I % I . /1.� available within 200 feet.) Installation will serve: Residence ___ Commercial _.. Othe Nurnber of living units: __. Number bf Qdrooms r Character of soil to a depth of 3 feet:' ' SEPTIC TANK ._� / s , '- Water table depth Ye Typo/Mfg 1.� — Cepacity��Dd No. Compartments I PKG. TREATMENT PLT. U f —��-- Melhod of Disposal _ Distance to nearest: Well _1Q(j_i• Foundation _ �Q.,— property.Line LEACHING LINE LI Nd. & Length of lines ; — • —Total length/size 'e _ FILTER BED [j—Distance to nearest: Well Foundation —Property Line SEEPAGE PITS I I Depth Size _...—_ _ Number SUMPS LI Distance to, nearest: Well_.. •— Foundation a Property Line • DISPOSAL PONDS Y IJ I hereby certify that I have prepared this application and that tris work will be dons in accordance with San Joaquin county ordinan rules and regulations of the Sann Joaquin Local Health District. ces, state laws, and .10 Horne owner or Iicernsedogent's sipnatuio Cbhifio's'tho-following:— ('certify that in the performance of the work for which this permit is Issued, I shall not employ any person in•suphpannor as to become subject to workman's compensation laws of California." Contractor's (tiring or sub -contracting signature certifies the following: °I co tifV It lot In fho rtormarice of the work for which this ormit is issued, I shall om to tion laws of California.'p P Y Persons subject to workman's cornponsa- The applicant ru call for. all eq vo ns`pactionis Complete drawing on reverse ,ell Signed >L -- _ Title: FOR iEPARTMENT USE ONLY Application Accepted hy; _ i -Isr' '—' o7F s�' _ Date r� %Area _ �_— Pit or 'Date _"'"' Final Inspection by Data rz r( Additional Comments: U Stk 486.6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 --- -- Applicant - Return all copies to: Environmental Health Permit/Sorvicos 1601 E. Hazalton Ave„ P.O. Box 2009, Stk., CA 95201 I c. I e EH 13-2/ IREV. Ell 14 2a FEE E AMOUNT DUE AMOUNT RMITTCK M INFO CASH RECEIVED 6Y MIT' 7a DATE PERNO. _ M1 --