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APPLICATION FOR PERMIT A�$ SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED 1601 E. HAZE T ON AVE., STOCKTON, CA 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. S %� Job Address �"" City Lot Size PM C. 0LACn v/ - y Owner's Name Address 'SA �� Phone � Contractor CLAM Address 2ALLYCT.i &,A k^License No. Phone a� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM 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 SPECIFICATIO S ❑ Indduu . I D Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing DL')" omest,;/Private D Gravel Pack D Tracy Type of Casing Specifications P Public D Other D Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I I astern S(ytfa e 5 •1 Installed by t _ Repair Work Done Type of Pump H.P. State Work Done_f�a l� Well Destruction D Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTFIUCTION I I (No septic system,permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size ? FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line s 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 District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perrriit-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-crintracting 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 Califor The applicant us call for all e i cti S. Co ete drawing on rev r side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by I.S1Date Z L I Area Pit or Grout Inspection byDate Final Inspection by �'— �6,r' ats /G' 0 Ag Comments: Stk 466-6781 EI 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A plicant- 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 CK CASH RECEIVED BY DATE PERMIT NO. + EH 13-241REV.iiNe) CA, EH 14-29 �l Alt,/ Cts