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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 (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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -` C Job Address de-no Alec ��. — __- Cit Lot Size P?, 74 PM Owner's Na Address a r QA® Phon �+ Contractor_ Addres License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 6\ Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type at Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by �) Repair Work Done ❑ Type of Pump H.P. State Work Done_ 0 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re 'dence Commercial— Other Number of living units: 17 Number of bedrooms `i Character of soil to a depth of 3 feet: Sd/Ir'O�✓ GdQ-Opt C�i� w/ Water table depth �a SEPTIC TANK 5Y7ype/Mfg r. L. Cap city �VdG No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well� Foundation /D , Property Line LEACHING LINE W--No. & Length of lines • Total length/size Z �3O FILTER BED © Distance to nearest: Well Z� Foundation It] Property tine SEEPAGE PITS IHrDepth Size Number SUMPS Ll Distance to nearest: Well-. }�� Foundation Property Line .19V DISPOSAL PONDS ❑ 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, 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st all for all Inspe ns. Complete drawing on reverse side. Signed X } Title: Date: FOR DE ARTMENT USE ONLY Application Accepted by Date '' J�[ Area it or Grout Inspection by r Date y` Ina) Inspection by Date dditional Comments: ❑ Stk 466-6781 © Lodi 369-3621 a -7104 ❑ Tra 5-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAFEEK If INFO AMOUNT DUE /AMOUNT REMITTED /CASH RECEIVED BY DATE PERMIT'NO. a.EH 13-24 IREY.1/n EH 14-28 v !!l lllfff / IIJJ