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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA F 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size -7 ,f PM Owner's Name �� r'�,� Address Pegs "o � Phone Contractor U(P? d Address il�!©,� � ,�.-`License No Phone TYPE OF WELL/PUMP: ,JNEW WELL ❑ _ WELL REPLACEMENT ❑- DESTRUCTION .0 . PUMP INSTALLATION ❑ SYSTEM REPAIR_ ❑ OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `� DISPOSAL FLD. �PROP. LINE FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SU INTENDED USE TYPE Ol WELL PROBLEM AREA CONSTRUCTION SP j S ❑ Industrial ❑ Open Bottom ❑'Manteca D" Excavation t Dia. of Well Casing ❑ Domestic/Private ID Gravel Pack ❑ TaType of,Cising Specifications M Public f] Other - Delta Depth-of Grout Seal Type of Grout , i I Irrigation x. Depth l I Eastern Surface Seal Installed by f Repair Work Done ype of Pump , H.P. State Work Done Well Destr ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commeicial _Y Other Number of living units: Number of bedrooms rsd kCharacter of soil to a depth of 3 feet. r¢ Water table depth SEPTIC TANK ❑ Type EI /t fgp Capacity r No. Compartments PKG, TREATMENT PLT. T Method of Disposal r. 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 I. I Depth I Size Number SUMPS 0 Distance to nearest: WellFoundation's _ Property Line r DISPOSAL PONDS ElE r _=�----�- r 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." Contractors 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.p6rsonssubject.to.workman:s-compensa- tion laws of California." plicant must call far all requ iespecY s. Complete drawing on reverse side. Signed X Title: Date: t FOR DEPARTMENT USE ONLY Application Accepted by Date �2 Z Area Pit or Grout Inspection by Data �823FinalInspectionby �+� y DateAdditional Comments. _ C❑ Stk 466 6781 ❑ Lodi 369 3621 ❑ Manteca ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I t FEE AMOUNTI]UE AMOUNT REMITTED CK RECEIVED BY INFO DATE PERMIT NO. a EH 13-24 iREV.I/A 5) - C>V 06 �r ry J - EH 14-26