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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. 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. Xjob Address 1 "/�'r City Lot Size PM P� Owner's Name A�ve Z6i21_-_1K Address �p 6� ��ss+d Q/ a Phone i Contractor_ Address ,W17�nta License No, Phoney_6�`0 to TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROSREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa El Tracy Type of Casing Specifications f'] Public F10 Cl Delta Depth of Grout Seal Type of Grout _. I I Irrigation _Approx. Depth { I Eastern Surface Seal Installed by _ Repair Work Do ❑ Type of Pump H.P- State Work Done Well Destr ion ❑ Well Diameter Sealing Material Stop 50'1 Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLA ON 1] REPAIR/ADDITION l I DESTRUCTION lNo septic system permitted if public sewer is available within 200 feet.) �A Installation will serve: Residence Commercial _w__ Other Number of living units: / Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel! Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines ___ Total length/size 4 I FILTER BED ❑ Distance to nearest Weli Foundation Property Line � r SEEPAGE PITS f I Depth Size _ Number SUMPS Cl 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 persons subject to workman's compensa- tion laws of California." - The applicant m all for quit d inspections. Complete drawing on reverse side. Signed _X' Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by , Date 7-1/ (J Area Pit or Grout Inspection by Date Final Inspection by / ` v��f Date Additional Comments: ❑ Stk 466-6781 Cl Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 F EO AMOUNT DUE AMOUNT REMITTED CK d CASH RE�CE/IjV�E'JD BBYY/J DATE PERMIT('NO. t.EH 13-24 4REV.1 i n sl -13 � — -j EH 1426 V 11