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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781. 0, W PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. /y7 Job Address l City Lot Size IoM. �7 . 6 1 Owner's Name Address Phone .a'` a Contractor Address 14W sJ License fVn �cs-��L Phone 0 TYPE OF WELL/PUMP: II: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER ES DISPOSAL FLD. PROP" LINE .i f. FOUNDATION AGRICULT WELL OTHER WELL PITS/SUMPS INTENDED USE .-;i u.a"TYPE OF WELL PROBLEMAREA- CO T CTION SPECIFICATIONS ❑ Industrial. ' ' •* "` ❑.Open Bottom ❑ MantecaDia. eEI Excavation Dia. of Well Casing ❑ Domestic/Private ❑:Gravel Pack ❑ Tracy T e of Ca g Specifications fl Public ., _ F1 Other F1 Delta epth of Grout eat Type of Grout I I Irrigation LApprox, Depth I I Eastern Surface Seal Insta d by _ Repair Work Done 'O',. Type of Pump _ H tate Work Done Well festruction ❑ Well Diameter ealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I:I EPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is II available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms t 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 ;F LEACHING LINE ❑ No. & Length of lines Total iengthlsize FILTER BED © `Distance to nearest: Well Foundation Property Line ,I SEEPAGE PITS i 1 Depth Size Number .i SUMPS Ll 11'`Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i,ll 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. st . Home owner or licensed agent'4s 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."Contractors 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." " 1�. � A. s The applica�t5�aallrequi ed inspections. Complete drawing on reverot igned XI Title: C date: ( [ �� ` FOR Of PARTMENT USE ONLY Accepted byor- ApplicationDate. �� Area *., Pit or Grout Inspectn b I Date Final Inspection by r f 1Date / Additional Comments: Stz L G^ + t'• I't x u �o ' El Stk 466-6781 Lodli ca 369-3621 ❑ Mante823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo1c2009, Stk., CA 95201//1.23 11FEE %7 INFO OUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. ` +.-EH 13-21(REV.t/k 5) ("jvv� EH,11-26 ��-++ 4