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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA O 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. s 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. f Job Address T _ 5 Na � City Lot Size �O P(vl i Owner's Name —VL.-.a Address Phone _. p Contractor KA_�"Al..,l_r Address 150 vV+ LUS:)("f[4icense No.'1 C>43 e),g Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- SEWEA LI S DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR L OTHER WELL PITS/SUMPS` INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRU�CTION SPECIFICATIONS �~ D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing © Domestic/Private El Gravel Pack El Trac Type of Casing�SL Specifications.: ' f-I Public ❑ Other ❑Pelta Depth of Grout Seal• Type of Grout ' I Irrigation _.Approx. Depth'- 1 Ea is ern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diametef Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I Wo septic system permitted if public sewer is available-within 200 feet) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line is LEACHING LINE ❑ No. & Length of lines 9 .Total length/size— FILTER ength/sizeFILTER BED ❑ Distance to nearest: Well Foundation Property fine SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line' DISPOSAL PONDS ❑ a 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� I rules and regulations of the San Joaquin Local Health District. ,' ,+ I 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 Tmploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cert,i he following: ' ftify that in.the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o Mao, ia.' IXT applican m II for �req drawing on reverse si e. 9 Signed Title: _ -_ _Date: FO DEPARTMENT USE ONLY T _,Application Accepted bypate /1 aa, q z Pit or Grout Inspection by /� to Final Inspection by Date T 7— Additional Comments: �✓�9 d S r=, z4ff ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ave.,-P.O. Box-2009,_Stk.,.CA.95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMn'NO. • EH13-24 IREv.$/x 51 SI �i `, ` EH 14-26 ro !J �f I