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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 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. ef .77"f 1 2'.5 Job Address � 7 City sr�l Lot Size PM Owner's Name ` U��fL Address � Phone llpa*, Contractor /`�" ' `A5 d'� `� Address /4YD C � License No.J�d-��y Phone TYPE OF WELL MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ x MP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI K SEWER LINES DISPOSAL FLD..— -- OP.-LINE— FOUNDATION _ AGRICULTURE WELL OTHER WE PITS/SUMPS INTENDED USE TYPE OF WELL PRO REA CONSTRUCTION (CATIONS f E3 Industrial 171 Open Bottom ❑ Manteca ia. Excavation Dia'.-of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type sing Specifications --1_1Public El Other to Depth of Grout Type of�Grout 11 Irrigation . Ap epth ❑ Eastern Surface Seal Installed by ' Repair Work Done Elpe of Pump H.P. State Work ne Well Destr a ❑ Well Diameter Sealing Material (top 501 ` Depth _ Filler Material {Below 501 ^; , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION)<(No septic system permitted if public sewer is i available within 200 feet.) Installation will'se_rve: Residence— Commercial_ Other /} ir/1P✓7/ Sc� Tr� � j� 1 J Number of living units: Number of bedrooms i 1 Character of soil to a depth of 3 feet: Water tabledepth SEPTIC TANK , ❑ Type/Mfg- Capacity-- No. Compartments PKG.`TREATMENT PLT. IJ ` Method of`Disposal Distance to nearest; Well Foundation Property Line � t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to-nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Thereby 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, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I car that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- 4 l tion laws of Californk The applicant must ca uired pec' Complete drawing on reverse side. J-7Signed Title: Date: ' FOR DEPARTMENT USE ONLY Application Accepted b Date�r z ,,l Area Pit or Grout Inspectio Date Final in, by � U1 CRS Date L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 8354M Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,�P.O:Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24 iREV.1/e 5) •y m 7 �� Eli 14-28