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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED No w �. (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. Job Address 140 City Lot Size PM Owner's Name 4 G ddiess S4 my e� Phone Contractor .Y� k I �+�` Address 05 Q License No. Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation CJDomestic/Private ❑ Gravel Pack D Tracy Dia. of Well Casing Type of Casing Specifications n Public D Other ❑ Delta Depth of Grout Seal I I Irril anonType of Grout —Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done D Type of Pump H p State Work Done, Well Destruction ❑ Well Diameter Sealing Material (top 50') ` j� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION o septic system permitted if Lpublic sewer is T Installation will servo: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C, Distance to nearest: Well Foundation Property Line LEACHING LINE s' t- F f❑ No. &Length of lines � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth Size Number SUMPS L-1 Distance to nearest: WellFoundation DISPOSAL PONDS ❑ Property Line 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, an 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 Signa 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 tion laws of California." The applicant must call for all eq red inspections. Complete drawing on reverse side. Signed X- , .� _ Title: �- G Date: p FOR DEPARTMENT USE ONLY Application Accepted by -fit — _ Date VL-3 Area Pit or Grout Inspection by Date Final Inspection by / !//'C/ f D t% Additional Comments: / � D Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO R RECEIVED By DATE PERMIT NO. + EH 13-211REV,11H51 '� EH 1428 7— �y