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APPLICATION FOR PERMIT Eo SAN JOAQUIN LOCAL HEALTH DISTRICTC_ 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. f' Job Address /vJ City Lot Size PM 76 Owner's NameAll '–r C Address + hoffe ';�y P , — Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TOSEPTIC TANK SEWER LINES DISP FLD. PROP. LINE FOU AGRICULTURE WELLOTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WI LL P REA RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Mantes Ia. II Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications i"1 Public Cl Other {1 Delta Depth of Grout Seal Type of Grout I I Irrigation TL Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ T of Pump H.P. State Work Done _ Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION (No septic system permitted if public sewer is of available within 200 feet.) 11 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 c ify 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 Ca r ia." The applica t call ail required inspections. Complete drawing on reverse side, Signed NA Title: r >"y[ ' Date: (/ FOR DEPARTMENT USE ONLY Application Accepted by Date , /� Area v 1 Pit or Grout Inspection by p `� Date Final Inspection by i Date S-76-D- 0 Additional Comments: F < 6 ❑ Sik 466-6781 ❑ Lodi 369-3621 LI 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 95291 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. ♦ EH 1124(REV.t/Ab) 16^3 �� EH 14-2a L