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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1YEAR 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. Job Address �6 0 City Lot Size(d4O x 264(© PM Owner's Na ��Lrn -�- Address _ � ePhone 714 7`r _. .._� _ __. 0 z Contract Address + 70_ � License No. 32 Rhone TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R ❑ OTHER ❑ DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINE' —DTSPOSAL`FEU.: "?RDP—L"11VE- FOUNDATION AGRICULT WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ nteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tract! Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done ype of Pump, H.P. State Work Done_ Well Destructio ❑ Well Diameter Sealing MateriaFitop 50') Depth - - -- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION RE?AIR/ADDITION I 1 DESTRUCTION 1 I (No septic system permitted if public sewer is nn available within 200 fee0 Installation will serve: Residence_.__' Commercial_ Other`M 6-A&.&tJ.Kq�yo 1� Number of living units: -i_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Jrd SEPTIC TANK Type/Mfo Capacity f aGd No. Compartments Z PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines — 0 kt Total length/size FILTER BED 11 Distance to nearest: WellINA—ItFoundation 'Property Line��' SEEPAGE PITS1 I �9epth Size oT X ID __ Number SUMPS L Distance to nearest: Well Lan44-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 Dibtrict. 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 shah not employ any person in such manner as to become subject to workman's compensation laws of Caffornia."Contractor's hiring or subcontracting 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 mt4g call for all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPA TMENT USE ONLY Application Accepted by Date r Area ,� ,�✓ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Heolltkt peclm. .Services 1601 EIYtfielton Ave., P.O. Box 2009! Stk., CA 95201 INF AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY !^ DATE PERMIT•NO. ♦.EH 1324(REV.t i e 5) �y/r EH 14.28 � i