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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. A ' pt Job Address [-�� 'V r"ll. 6 bf�-�O�/'� Ave- City;�L LD Size 9b M Owner's Name ` 4 1 r C0&1Address2_ / j� f �[_ jCJIC J�--1 AVC Phone �.s� O 451c- Contractor �' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP R ❑ OTHER ❑ DISTANCE TO NEAREST: PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOU TION AGRICUVIdgE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF PROBL REA CONSTRUCTION SPECIFICATIONS El Industrial El Open Bottom nteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tra Type of Casing_ asing Specifications El Public El Other El Delta epth of Grout Seal Type of Grout C1 Irrigation �4ppr . Depth ❑ Eastern Su ea In by Repair Work Done ElType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is v ilable within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a dpth of 3 feet: Water table depth SEPTIC TANK Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. 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."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 apphcan ust call for ll required insctions. C plate drawing n rave side. n Signed Title: rave Signed 1 Date: J5 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b �D7ate Final Inspection by Date vt Additional Comments: !,-�„�,4 ��5 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 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 'A?S�H/ + EH 13-24(REV.1/95) EH 1426