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�r Y APPLICATION FOR PERMIT A 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 fmade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin If 1 Local Health District. / +Job Address i /� �� ©��""� City �L`6t Size PM M. Owner's Name A EE�rPte'f Address _ bne8 r - yL Contractor Address License No. Phone TYPE OF WELL/PUMP: A/NEW WELL ❑ WELL REPLACEMENT © DESTRUCT 1 PUM�NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DSTAN O NEAREST:--SEPTIC TANK SEWER LINES POSAL FLD- PROP, LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS iNTENDED,USE �- PE OF,WELL PROBLEM CONSTRUCTION SPECIFICATIONS ❑ Industrial � ❑ Open anteca Dia. of Well Excavation Dia. of Well Casing L7 Domestic/Private © Gravel P racy Type of Casing Specifications Fl Public ❑ r ❑ Oelta Depth of Grout Seal Type of Grout I I Irrigation t _Approx. Depth 1 1 Eastern Su al Installed by--- o y _ � Repair Work D ❑ Type of Pump H.P. ate Work Done_ t Well De tion ❑ Well Diameter Sealing Material '(top 50') 'Depth .I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTIO ! INo septic system permitted if public sewer is ¢ vailable within 200 feet.) Installation will serve: Residence Commercial_'Other Number of living units: Nuimber of bedrooms Character of soil to a depth of 3 feeit: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments {� PKG. TREATMENT PLT. ❑ - I -v Method of Disposal 5 Distance to nearest:��We-11 Foundation Property Line € LEACHING LINE ❑ No. & Length of lines Total length/size Er FILTER BED 0—Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1.1 `,Depth I Size Number i i 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 empioy any person i manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol) : _16 "16 th in the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o alif rni t v The pr ant mus cal for all r quir i tions. Complete drawing on reverse side. h Signed X Title: Date: 61 X rr n� FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: 1 ❑ Stk 466.6781 ❑ Lodi 369-3621 Cl 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 I k FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO ASH r.EH13-24 iREV.V n 51 EH 14-2ti