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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (Complete in Triplicate) Application is ha+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ounty Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin C Local Health Oistf" !15. X11 �l ;26t9 G PM City Lot Size Job Address Address l� ) i"r!/ to 0"o __ Phone Uav Owner's Name Do ' v Address�O r �1�DCl��t[r � License No. Phone 13`160k3l Contractor N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .� '1 Public F1 Other F Delta Depth of Grout Seal Type of Grout I I irrigation Approxi Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 f Depth Filler Material {Below 50') TYPE Of SEPTIC WORK: NEW INSTALLATION-T. REPAIR/ADDITION 1 I DESTRUCTION I I al o septic sy t m rented if public sewer is { Installation will serve: Residence! Commercial_ Other ` Number of}living units: Nyumber of edrooms Character of soil to a depth of 3 feet! Water table depth �] SEPTIC TANK Type/M16 P Capacity No. Compartments 2 PKG. TREATMENT PLT. L1t,t Method of Disposal bistancd to nearest 1 Weil ?+90 Foundation #�-+ 1 Property Line S r LEACHING LINE No. & Length of lines "vet Total length/size LEACHINGP- Z p f F i Well1 �(�1^ .4 Property Line +�f FILTER BED ❑ Distancerto nearest: _ _ Foundation_ __ ! �Niimber + SEEPAGE PITS I-r Depth '� f 13 �_--Size + — I� SUMPS C7 Distance,to neo r T Well—.-' CTO Foundation_ _L— Property Line '- `1 DISPOSAL PONDS ❑ -.,t+ I:!-{=``�' 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. 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, 1 shall not 1 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 California." f + I r > The applicant':must call for all quired inspections. Complete,drawing on reverse side.oe '� /2 + V Title: �L�.{�L/ Date: Signed I { FR DEPARTMENT USE ONLY 1� Application Accepted by Date �"� — Aea � r } Date l Pit or Grout Inspection by Date Final Inspection by Additional Comments: C] Stk 466-6781 171 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 . . IMF 1^J[+!� DESCRIBED HER50 11, k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. tq��yy --- �1r9;T1{�l+1 a r7-(`( lrr�A[PP/RO1/' NYw0(!'l'r��f9- .'�r_�.+.Jr...�� f1 LldUI1 E1..IPCr FT�P`F IJ FEE GK AMOUNT DUE AMOUNT REMITTEDCASK RECEIVED BY DATE ERM47'NO. INFO +-EH 13-24(REV.+/A F,) EH N-2B