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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 TYEAR 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. Kis Job Address X City E �' Lot Size - PM Owner's Name l /1' Zh'C 4 _' 'i'A'ddress ,' ? �' !� V Z Z Z-4/ ?�VG ° / Phone � Contract . _ _ Contractor Address� �^� "" -- - `" License No. 31' �"� �� Phone T F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 6P PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE- O-NEARE5 IC TANK SEWER LINES DISPOSW�E�L L FLD. PROP r _ + FOUNDATI AGRICULTURE WELL OTHER PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM A ONSTRUC CIFICATIONS s . ❑ Industrial ❑ Open Bottom ❑ Manteca o e nation Dia. of Well Casing [�} ❑ Domestic/Private _❑ Gravel Pack ❑ Tr Type of Casing Specifications d I 1 Public = ❑ Other F] Delta Depth of Grout Seala of Grout _ I I Irrigation 'R' ' prox. Depth !I l Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done t Well D .. ction , ❑ Well Diameter Sealing Material Stop 50'1 i Depth Filler Material (Below 50') ^ i TYPE OF SEPTIC WORK: NEW INSTALLATION 1'�i, REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is , - = r available within 200 feet.) Installation will serve: Residence— Commercial__ZOther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: �-�" " `" P _ Water table depth ; . SEPTIC TANK 4 -_0J'jT_yp_eiM 9�'�� '`" Capacity �` '��' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t ,• j Distance to nearest: Well �"""J_ Foundation :'-f Property Line f I LEACHING LINE 0 No. & Length of lines �� C:" /� � r Total length/size: FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS f`I Depth Sizeu Number "c.:' IN. SUMPS (_I 'Distance to nearest: Well r Foundation-_.�* Property Line . `5 DISPOSAL PONDS Cl 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. x' 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 F 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 applicari must call for all requiretl inspections. Complete drawing on reverse side. I F Signed X'� - Title: R f •.�,?..«-�,.�-'"y _ -; ; � --.1 Date: ,! t: 1 FOR'DEPARTMENT USE ONLY ,. x Application Accepted by _= "� Date = f7 Area f t Pit or Grout Inspection byy Date ' � ' ': ,_ Final Inspection by Date ^� r Additigrial Comments: �' 6 ❑ Stk 466-6781 ,---0 Lddi= 359-3621 ❑ Manteca ''823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FE E It T' INFO ,AMOUNT DUE AMOUNT REMITTED CA H RECEIVED 8Y DATE PERMIT'NO. ♦.EH 13-241REV.tiH51 - :.` `/ D. I� `? 7 �/ �U 6V EH 14-Ze r