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APPLICATION FOR PERMIT -- --SAkl,JOAQUfN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) .466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 1 p�.�1TieICE 5T City STi�� Lot'Size'S©x l�� PM Owner's Name Ra,9e_/_Y' AIAGEIVAAI Address 4A'w-11Ca - u Phone 44�' r AOS2 b Contractor 45• Woa� Address 4-0 1- Ati- f I—L.I'A&J License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,`• DISTANCE TO NE T: SEPTIC TANK SEWER LINE S �� / DISPOSAL FLD. PROP. LINE r NDATION AGRICULTUREAn1ELL OTHER-WELL PITS/SUMPS INTENDED USE TYPE 0 LL PROBLEM AR CONSTRUCTION SPECIFICATIONS : I i ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatioh"'"�`"�"'�""'" Dia. of Well Casing y ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications t ❑ Public ❑ Other elta Depth of Grout Seal Type of Grout ❑ Irrigation _—Approx. Dep ❑ Eastern Surface Seal Installe&by Repair Work Done�1❑ Type of Pum H.P. ! State Work Done Well Destruction 'Cl Well Diameter Sealing Material (top 501 k t i Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic.system permitted if public sewer is f available within,200 feet) Installation will serve: Residence_ Commercial_ Other Number of living ts: Number of bedrooms j a yi`fi Character of soil to a de of 3 feet: —Water table depth SEPTIC TANK Ty fg # Capacity f No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to neare ell Foundation Property Line LEACHING LINE ❑ No. & Length of)rles f Total length/siie FILTER BED ❑ Distance to near/est: Well Foundation T Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well 5 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 District. - Home owner or licensed agent's signature certifies the following: "I certify that in the performance of theswork 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 must call for all required inspection Complete drawing on/reverse side. Signed X Ij Title: Date: `Z FOR DEPARTMENT USE ONLY ] Application Accepted by Date �^ �— Area Pit or Grout Inspection Date Final Inspection by Date'? Additional Comments: 4�PO 12 ❑ 8tk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 t 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 RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24 IR EV.1/851 $� EH 14-26 ��t7 G