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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA rl 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. A Job Address � �j /' ,) A1 City Al Lot Size PM Owner's NameAwe4. AseilA Addresses " Phone / Contractor �' ,�/ .0�G-tA? ddress �/�✓►d� �L� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WE REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION"[ZJ5_AfYSTEM 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 ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ElGravel Pack ElTracy Type of Casing Specifications Public ❑ Other C Delta Depth of Grout Seal Type of Grout I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump --� H.P. State Work Done_ �, 01 Well Destruction ElWell Diameter Sealing Material (top 50'1 1 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is 4�_. available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedroom (� Character of soil to a depth of 3 feet: At Water table depth �J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ,foundation Property Line SEEPAGE PITS I I DepthSize _ Number SUMPS Ll Distance to nearest: Well Foundation PropeWbne 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 _ 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 wokman's compensation laws'of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work4gr which this permit is is§ued;I shall employ persons subject to workman's compensa- tion laws of California." i The applicant req ctions4 Complete drawing on reverse ' Signed X s Q itle: '' ` Date: F DEPARTMENT USE ONL Application Accepted by / i� Date �X Area n � Pit or Grout Inspection by Date Final Inspection by Date Y Additional Comments: �( ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. a.EH 13-24(REV.t i n 5) 3-5� EH 14-26 «c.��