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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA J� l Telephone (209) 466-6781 r ' 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. Job Address b©o \v e4/�v ity �' Lot.Size tG,e— PM Owner's Name 4M A2AtQ,0L:S/ � Address �i Phone Contractor .Cl i 1 Abl,/__kl Address r"-2 e�e License No. . /S Phone TYPE OF WELL/PUMP: ; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: kPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ____ PITS/SUMPS INTENDED USE ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑I.Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack iD Tracy Type of Casing Specifications FI Public 177� Other lilnDelta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth l I'Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50'1 r Depth Filler Material 10elow 501 TYPE OF SEPTIC WORK: ;NEW INSTALLATION RFPAIR/ADDITION i l DESTRUCTION I I Mo septic system permitted if public sewer is } t - .available.within`200-feet.l- installation will serve: Residence P Commercial_ O her t Number of living units: ,..... Number of bedrooms b Character of soil to a depth of 3 feet: Pig Egg, 3 Water table depth SEPTIC TANK ❑ Type/Mfg ,,4 i acit _`__' p w'',`No.`'Compartments ` PKC. TREATMENT PLT. EliCa y �x Method of Disposal Distance to nearest: Well_ O FounclationProperty Line LEACHING LINE No. & Length of lines7 � - i Total length/size 42 FILTER BED ❑ Distance to nearest:s Well 4MfF..ndab,n Property Line . f � SEEPAGE PITS I I Depth Size,. 'y }' _ Number Y i SUMPS Ll t Distance to nearest: Well Foundatiori '"" '"- P Y- DISPOSAL PONDS ❑� . 1 hereby certify that I have prepared this appiication 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 Diltrict.,1. r 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 shall note employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." f q The applicant must call fpr fll required inspections. Complete drawing on reverse side. Signed X r S -%v, .Title. f FOR'fJEPARTMENT USE ONLY Application Accepted by tl1}{}�, f t Date Area Pit or Grout inspection by r Date Final Inspection by � Date ' Additional Comments:s' f ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 — � INFO AMOUNT DUE AMOUNT REMITTED 9�— ;I �C�C RECEIVE BY DATE PERMIT'NO, EH13.24 IREV. i x 51 -r r02 EH 14-26 11