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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 C)4 - 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. Job Address -14,20// )a . Cit r Lot Size PM Owner's Name llr-'i� /�f � KAdress �0� Q Phone Contractor Z 1— ka.✓!0/e-Address License No.,54 In.53Y Phan�I- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private El Gravel P��Frl cy Type of Casing Specifications I1 Public 171 Otherelta Depth of Grout Seal Type of Grout I I Irrigation �ype .f x. Depth I I Eastern Surface Seal Installed by Repair Work Done mpH.P. State Work Done Well Desiru - ❑ Well Diameter Sealing Material (top 50'), Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is a ailable "n 200 Jeet. __.�__ l ` e Installation will serve: Residence Commercial_ Other ��(T/ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water to a depth SEPTIC TANK ❑ Type/Mfg Capacity No. 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 I 1 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 follow' "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 Calif.rni ." The applic s all for equire ctio tete drawing onIrver;XS10. 5- Signed Signed Title: Date: FOR DEPARTMENT USE ONLY q Q Application Accepted by Date l� �x Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: Q ` e-?i ❑ Stk 466-6781 c/0 di 369-3621 Manteca 823-f104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box M, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'��N111O. +.EH 13-21(REV.1195) � EH 14-26 v