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APPLICATION FOR PERMIT ry1 SAN JOAQUIN LOCAL HEALTH DISTRICT 0 1 1601 E. HAZEL i ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 fSr well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / r City Lot Size f Dt' PM '/` Owner's Name A4kl X /� / Address �4'4M A"""t_C11. Contractor �aT +d Address AO l�sl S"5'�l357X_& License No._4', 3 Phone OF WELL(PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ElF OTHER ❑ DISTANCE TO NEA T: SEPTIC TANK SEWER LINES DISPOSAL FLO. PR E. -� DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE 0 PROBLEM AREA CONSTRUCTION SPEC 5 ❑ Industrial C1 Open Bottom anteca Dia. of Well ron ' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casing Specifications ❑ Public ❑ Other i Ll t f Grout Seal Type of Grout I Irrigation __Approx I I Eastern Surface Sea d by A J�1 i Repair Work Done ❑ a Pump H.P. ork Done Well Destr ❑- Well Diameter Sealing Material It 50'I ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system'permitted if public sewer is available within 200 feet.) Installation will serve: Residence X_ Commercial_ OtherIL Number of living units: 4— Number of bedrooms 10 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg &Z Capacity o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Ada f Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 3 �� Total length/size � O FILTER BED ❑ Distance to-,nearest: Well Z *!!! Foundation �a )Property'Line SEEPAGE'PITS i1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 fallowing: "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 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 Calif ia." The applican t call all re ired ins on Complete drawing on reverse side. Q Signed A Title: _ Date: .br n1DEPAR, ONLYApplication Accepted by �"� ` to Area Pit or Grout Inspection by Data Final Inspection by Date orAdditional Comments: ❑ Stk 466-6781 ❑ Lodr 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a r FEE t INFO UNT DUI: AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. - EH 13-241REV.r/x51 X 114i0a P A-1mac+EH 14.28