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APPLICATION FOR PERMIT h t SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 1 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED >;• x. (Complete in Triplicate) N m = I 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 i 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 ' 0 V vi,, City � G��o f1 Lot Size PM -' Owner's Name Cl o f -041Lf., YGTt125vi,- "Address Sr4y►� Phone �i�vl79�5'- i I6l-94P Contractor -R - `�� 3 `�JAddress 6 �V` �t°sok �� License No.�— y3 Phone 7 F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4s DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A CULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AS C STRUCTION SPECIFICATIONS Ll Industrial ' 0 Open Bottom - 11 Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack FiTracy a of Casing Specifications O ❑ Public ❑ Other ❑ Delta ,,Dept f Grout Seal Type of Grout ❑ Irrigation ---Approx.4pprox. Depth t O' 'Easte Surface, al Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION LJ 'f DESTRUCTION (No septic system permitted '+f public sewer is t available within 200 feet.) 7 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg j.:�,.y rapacity No. Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest' Well Fou6 da-tion Property Line 1 f I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED . � ❑ Distancei:to nearest: Well VFoundatian•-��9 Property Line I � ( SEEPAGE PITS ❑ Depth Size a Number e •ter G' #-�`' � f. SUMPS ❑ Distance to nearest:. Well f Foundation,} . Property Line DISPOSAL PONDS ❑ i ! ' I 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 st all for ail req ' d ' pections. Complete drawing on reverse side. Signed ' 1�n OW d Title: Date: I FOR DEPARTMENT USE-ONL•V ' Application Accepted by Date Area Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 171 Lodi 369 3621 El 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 CASH RECEIVED BY DATE: PERMIT N0. INFO G + EH 13-24(REV.I fi 5) r��-i�U EH 44-28 1 - -