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APPLICATION FOR PERMIT s 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 i 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. Job Address E COM S7e>Q 1 City 5 ll Lot Size 3 C 'S PM Owner's Name D1e.1ne S9-my- e, Address 14C)61')0 67 OM- Phone _ 'r -- D2P Contractor's Name 42� `" S�}_ r�x]T,e2 _ "License No.- _ , Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 3 DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ A ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout }� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1' Repair Work Done ❑ Type of Pump H.P. State Work Done { Well Destruction ❑ Well Diameter Sealing Material stop 50'1 '.. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION)f DESTRUCTION C1 (No septic system permitted if public sewer is "� /eavaiiable within 200 feet.) Installation will serve: Residence_X Commercial_: Other Number of living units:7±1 `;Number of bedrooms 3 Character of soil to a depth of 3 feet:N, table depth { SEPTIC TANK Cil►St 11Type/Ml ic le a Capacity.-,f No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: W000� Foundation__46!0! - Property Line _ r F LEACHING LINE No. & Length of lines ARDW. 40l -� ee,4k Total length/size 'i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth r> Size 33z Number 46Y14E� f r SUMPS 11 Distance to nearest: Well Foundation Property Line �I DISPOSAL PONDS ❑ i 1 hereby certify that I have prepared this application and that the workwill 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 agents signature ce'rt'ifies 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 certifVthat 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 must call for all re sped' ns. omplete drawing on r arse sicA Signad Title:- Date: of�"' . FOR DEPARTMENT USE ONLY Application Accepted by A Date Area y Pit or Grout Inspection by*4x Date �� Final Inspaction by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C7 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 95201 f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIr NO. ` + EH 13.24(REV. 10183) EH 14-28 Lis. C]O