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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 Joaqn 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 6-�g 2 17 A lP ion et City A?4 Lot Size PM � IF Owner's Name La Me RRA Address V261a,27 Phone Contractor L /`U�fis/v Address I 4. �� ! License No. Phoneg TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approxi Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type 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 I I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) v1 Installation will serve: Residence 400�'Commercial_ Other Number of living units: 4— Number of bedrooms Character of soil to a depth of 3 feet: Nf�V � /✓� Water table depth SEPTIC TANK ElType/Mfg 9U,4+ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method,of Disposal Distance to nearest:• WeIAT 7 Foundation�,rrte� Property Line IIgy LEACHING LINE No. & Length of lines !V T Total length/size oS FILTER BED ❑ Disve to nearest: , Well_SZJ77 4ouodation F <t'foperty Line: SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation .Prpperty 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, andI rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifiesthe 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 applicant must call for all required inspections. Complete drawing on reverse side. •, w Signed X `� Title: `Date: 'Po- F DEPARTMENT USE ONLY Application Accepted by Date/- Pit atePit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t" „FEE `.x AMOUNT DUE"v 'AMOUNT REMITTED GK.CA RECfJVED BY DATE PERMIT O. IIYFO + EH-13-24(REV.ribs) EH 14-28 C �. ... / d