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r APPLICATION FOR PERMIT 'E ` SAN JOAQUIN LOCAL=HEALTH DISTRICT ,; 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED I (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 J ?2. z _J� IL A/:!;3' City Lot Size _Z:C 1 y4'__ PM r ,qGG—XAiJ �/� Owner's Namem Address Phone I Contractor F401YD 14&07Address Al, Afa��z3 � License No. '1214 A' Phone 5 J=397/ I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SE R LINES D POSAL FLD. PROP. LINE FOUNDATION AGRIC TURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial C1 Open Bottom ❑ Manteca Dia. f Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type o asing Specifications ❑ Public {7 Other .I elle Depth of G t Seal Type of Grout I 1 Irrigation - _..Approx. D i I Eastern Surface Seal Ins led by Repair Work Done ❑ Type of P p H.P. State Work Done _ t, Well Destruction ❑ Wei �ameter -Sealing Material Itop 50'1 Dep Filler Material i8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION i I DESTRUCTIONINo septic system permift'd if public sewer is I � available within 20D feet.) " Installation will serve: Residence_ Commercial_' Other Number of living units: -7/— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Q LEACHING LINE ❑ No. & Length of lines Total length/size s e FILTER BED ❑ Distance to nearest: Well Foundation Property Line ((� 1 ' SEEPAGE PITS I I DepthSize Number SUMPS 0 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 followingTI 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." •I The applicant must cal for all required inspections. Complete drawing on reverse side. Signed X ATitle:_ &2zextf Date: �- 1 40 i .FOR DEP MENT USE ONLY t J Application Accepted by Date y�/�� Area Pit or Grout Inspection by Date Final Inspection b Date r Additional Comments: F ❑ Stk 466-6781 ❑ Lodi -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 r� INFO AMOUNT DUE AMOUNT REMITTED OK RECEIVED BY BATE PERMIT NO. +.EH 13-211REV.t/H5Y '�.:/�� I f:�0 EH 14-28 `I