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APPLICATION FOR PERMIT � n n��) O� '' -'� 1 0 SAN JOAQUIN LOCAL HEALTH DISTRICT cict 1601 E. HAZEL T ON AVE., STOCKTON, CA ,y Telephone (209) 466-6781 �✓'V�'11 ` �aw�� 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. n , / Job Address �f„�� 11 �L�L/9 /�1• City ES'C#410n! Lot Size PM Owner's Name d Afee T 0C A 91 Address Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Well Casing ❑ Domestic/Private ElGravel Pack ElTracy Type of Casing cifications 1-1Public El Other 11 Delta Depth of Grout Seal a of Grout ❑ Irrigation _gpprox. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC=WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ■ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation wilrserbe: Residence-A— Commercial_ Other Number of liying units: Number of bedrooms .3 Character of soil to a depth of 3 feet: A3013E. Water table depth SEPTIC TANK t, ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT 141-T. ❑ Method of Disposal Distance IG-nearest: VVe*— ur1'datioin 'ply® Property Line LEACHING LINE ._ i + � P-_ No.& Length of lines Total length/size FILTER I3ED ❑ Distance to nearest: Well /00• t Foundation SM Property Line SEEPAGE PITS ! Depth 2S Size Number SUMPS ❑,,Distance-to-nearest: Well jQ42(4— -Foundation Property Line DISPOSALPONDS ❑ rL �— 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 follgwing: "I certify that in.1he perfofmance of the work for which this permit is issued, I shall not employ any person in such manner as to become sub1ect 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 cornwhsa- tion laws of California." The applic nt must call for all required inspections. Complete drawing on re erse side. Signed k Title Date: FOR DEPART ENT USE ONLY Application Accepted by Date_ _ Area / f Pit or Grout Inspection by Date Final Inspection Date 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 RECEIVED BY DATE PERMIT'NO. + EH 13-24IREV.vHs) EH 14-26 V/ e Wt 6;C O ��++ii�� t