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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3-� 3601 E. HAZELTON 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. j� , Job Address [__X3/ CA �.,_ City_ /V, Lot Size _ PM Owner's Name��1 { Ed r fi Ul Address 0J4 1 Cam-, Phone Contractor Address/-Pr—(if )2V aR__ License No.T 3 6'Z-3 _Phone?A 3"— 'J TYPE OF WEhL/PUMP: NEW WELL ❑; WELL REPLACEMENT ❑ DESTRUCTION i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OiHER ❑� DISTANCE-TO'NEAR EST::SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION 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 I ❑ Domestic/Private ❑ Gravel Pack fl Trac Type of Casing Specifications f Public FI Other n Delta Depth of Grout Seal Type of Grout W Yp \11 Irrigation __-Approx. Depth l I Easterni. Surface Seal Installed by _ Repair Work Done 11"'1 Type of Pump H.P. `. Stat Work Done Well Destruction Wel! Diameter Sealing Material (top 501 A - 7 37 1P Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIR/ADDITION 1 I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence Commercial_�_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg r. CapdCity No. Compartments PKG. TREATMENT PLT. 171 it._ y Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED D Distance to nearest: Well Foundation Property Line '•. SEEPAGE PITS I 1 Depths Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ h j 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 M1trict*,, "l certify that in'the per Home owner-or licensed agent's signature certifies the following: formance of the work for which this permil`is issued;,)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 ' 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." The applicantList ca I for all re Vd , pections. Complete drawing on reverse sid f C_ ( / Signed X Title: O Date: f / FOR DEPARTMENT USE ONLY '• Application Accepted by CA Date ' . Pit or Grout Inspection by Date Final Inspection by Date i i l Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 1 ,Applicant- Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 W E AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY f CASH DATE PERMIT NO. `.+.EH 13-24{REV.r/n 51EH 14-26 �... I