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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. � { cff h City Lot Size PM Job Address , Owner's Name C_7 A�y A. `x 7 Address /0- I* 1,44011! Ale Phone `TY3 AllkContractor �z �F Address r�P "� License No. f —Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. 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 El Domestic/Private ❑ Gravel Pack LITracy Type of Casing Specifications r7 Public ❑ Other 1=71 Delta Depth of Grout Seal Type of Grout I f Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by _ O Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I'1 REPAIR/ADDITION l 1 DESTRUCTION,X INo septic system permitted if public sewer is } available within 200 feet.) Installation will serve: Residence— Commercial_ Other 3 Number of living units: Number of bedrooms ,. I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ll Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line z' _1 LEACHING LINE ❑ No. & Length of lines r ; Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS f 1 Depth Size Number r SUMPS ❑ Distance to nearest: Well f Foundation Property Line DISPOSAL PONDS ❑ 4 r 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. t 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 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 applicant-. st call for all required inspec io s. Complete-drawing on reverse-side. Signed � � Title: __+ _ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by sr�� Date Z'"t — �� ' iJ Area Pit or Grout Inspection by (DDate C�Final Inspection by l G��1C�i� Date Additional Comments: � S a1 �Y3. ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1W1.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CAScK H RECEIVED BYDATE '1PERMIT'NO. rEH 13-24(REV.i/n 5) J- Q © 64 // 271 2 EH 14 26 y7