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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICTh�"I!. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED }_ (Complete in Triplicate) /� �� to the San Joaquin Local Health District for a permit to construct and/or install the WOrk fSe n-do .lhkiPp lt. AOS/ 4 Application is hereby made q 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 Local Health District. t r Job Address �' w Cit Lot Size PM i04 ' ''Phon ,+� S Owner's Name415 Address � (� f Atldre License ) —Pho� Contract +TYPE OF WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT 11 DESTRUCTION El PUMP INSTALLATION ❑ -T SYSTEM REPAIR ❑ OTHER 17 DISTANCE TO NEAREST: SEPTIC TANK SEWER ❑NES DISPOSAL FLO. PROP."LANE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU INTENDFD USE TYPE.OF WELL—PROBLEMAREA""'CONSTRUCTION SPECIFICA ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc Dia. of Well Casing J{ 4 ❑ Domestic/Private ❑ Gravel Pack; ❑Tracy asing Specifications (l Public ❑ Other C 1 D Depth of Grout Seal Type of Grow-- S F rr4.s' ; E 1 Irrigation _:-Approx.'O l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type umpi H.P. State Work Done_ „ Well Destruction ell Diameter;. T` Sealing Material (top 50'1 i Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION is REPAIRIADDITION l 1 DESTRUCTIO JNo septic system permitted if public sewer is ,--available within 200-feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms 1 I Character of soil to a depth,of 3 feet:•-yam Water table depth Capacity ` SEPTIC TANK Ll Type/Mfg Y No. Compartments - PkG. TREATMENT PLT:❑ _ Y —' Method of Disposal -tet Distance to nearest: Well Foundation Property.Line fi 7' LEACHING LINE � Cl •4No. & Length of fines, Total length/size FILTER BED D: Distance to nearest: Well Foundation Property,.Line, SEEPAGE PITS I 1 Depth t R` ? "Size Number. 1 SUMPS L� Distance to nearest: Welt` f Foundation Property Line —._7 ' DISPOSAL PONDS ❑ _ 1 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. !t nHome 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 s '-.employ.arkV person in such manner as to become'subject to workman's compensation laws of California." Contractoes 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 a tion laws of California." Esc The applic"mus, r all required inspections. Complete drawing on rev a side. art, — 4 n Sig , Title: Date, — _: FOR DEPARTMENT USE ONLY - , f Application Accepted b Dat Area �Q_ _ Z . ' Pit or Grout Inspectio by Date Final ins coon b{ ver "��y 4 9t)ate:F�"+ ' Additional Comments: - 33 a 1O ❑ Stk 46fi-6781 ❑ Lodi 369-i6il ❑ Manteca 823-7104 ❑ Tracy 835.6385 " ''1 Applicant - Return all copies to: En ,ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 p �� FEE AMOUNT DU AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO."r INFO ` — , +.ER13-24{ REV.t/n51 EH 14.26