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.t _.rte APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA G Telephone (209) 466-6781 4 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. 9 Job Address `J 1 \Z1 QVC City _ O —4"Lot Size PM Owner's Name. 6LLA Address �� L. Phone T-07 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ a `' - ` ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK " ;SEWER LINES DISPOSAL FLO. P r{ FOUNDATION t� AGRICULTURE WELL OTHER P1TSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ECIFICATIONS ❑ Industrial LJ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications Fl Public M Other C Delta Depth of Grout-Sea[ Type of Grout 11 irrigation prox. Depth 11 Eastern Surface Seal installed by Repair Work Done Type of Pump H.P. State Work Done _ Well Des on ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l I DESTRUCTION- (No septic stem:permitted if " p y p public sewer is a available within'20i feet.) f installation will serve: Residence_ Commercial_ Other f' „� — - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table d"e"pth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS i I Depth Size Number i SUMPS 0 Distance to nearest: Well Foundation Property Line ! 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, i shall employ parsons subiect'to workman's compensa- tion laws of California." T licantt call for all required inspections. Complete drawing on reverse gide. Signed X tie: S Date: FOR DEPARTMENT USE ONLYAM r E.. Application Accepted by C} f!'� Data If)_IA 1V\ Area Pit or Grout Inspection by ]y Date Final Inspection by Date' 7 Additional Comments: : n. Nz— Q,0At b I Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 ' Applicant Return all copies to:.Environmental Health Permifl.Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMtlUNT REMITTEDCK CASH RECEIVED BY DATE PERMIT-NO. + EH13-211REv,1 5 M.� sl EH T4-2B r . f