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APPLICATION FOR PERMIT il SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 II PERMIT EXPIRES TYEAR FROM DATE ISSUED 4 (Complete in Triplicate) i 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 r Local Health District. Job Address T�'L3 8�sr�/,c1 L,t�„_ City'*577-7-'Al Lot Size PM Owner's Name E�P.v e A Address S.4rr1_1 Phone 7 7 Contractor�._,c.o- D_6. &,&07> Address bd64 � License No.�� Z b Phone gb.C-3 15l']/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR�EolOTHER ❑DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,FLD. PROP, LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. ofZ ❑ Domestic/Private ❑ Gravel Pack ❑ T y Type of Casing Specifi f'} Public f 1 Other Delta Depth of Grout Seal Type o _ I I Irrigation _-Approx. th l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of P p N.P. State Work Done Well Destruction ❑ Well DiameterSealing Material (top 501 i Depth Filler Material (gelo�v 501 i TYPE OF SEPTIC WORK: NEW INSTALL TION I 1 REPAIR/ADDITION [I DESTRUCTION (No septic system permitted it public sewer is 4 ' , J9, 1,7 ” available within 200.feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: -4— Number of bedrooms `' t Character of soil to a depth of 3 feet: A-�'4 - — — Water table depth SEPTIC TANK ❑ Type/Mfg " acit ,, p y No. Compartments PKG. TREATMENT PLT. ❑ > °- -~- - Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines } Total length/size FILTER BED ❑ Distance to nearest: Well Foundation `f .Property Line i SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well 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. I 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 not employ any person in such manner as to become subject to workman's compensation laws of California."r Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this ermit is issued,1 shall em to tion laws of California." - — - p _ ,I shall p y persons subject to workman's compensa- . The applicant must call for all required inspections. Complete drawing on reverse sAF ide E Signed X Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted byV VV Date �� Arca q,p Pit or Grout Inspection by Date Final Inspection by Additional Comments: No i ❑ Stk 466-6781 ❑ Lodi 369t621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 IE Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AM?OJNT REMITTED CASH RECEIVED BY .� DATE PERMIT•NO. +•EH 14-24 1REV.i i H s1 3J low— EH 14-26