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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601-E: HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 e� PERMIT EXPIRES TYEAR 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 7 i�t�i/U /�7� City Lot Size PM Owner's Name Address Phone Contractor R � A)a w �Lw�t'poless -3J l J C License No.�Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR*"❑"'j OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dial of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications '1 Public 1-1 Other ❑ Delta DeptFi of Grout Seal Type of Grout 1 Irrigation ___Approx. Depth 12 Eastern y Surfle Seal Installed by i i Repair Work Done ❑ Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION t I DESTRUCTION I 1 INo septic system permitted ifpublicsewer is i } available within 200 feet.) Installation will serve: Residence in__�Commercial 4'-• --Other Number of living units: –)-- Number of bedro ms f Character of soil to a depth of 3 feet: Cft U Water table depth SEPTIC TANK ) Type/Mfg C_k–C�� r Capacity � No. Compartments PKG. TREATMENT PLT. 0 � +' � Method of Disposal Distance to nearest: Well --Foundation� Property Line 3_.T u Vzl, L I r 1,--,j P,+ a LEACHING LINE �`r'No. & Length of linesTotal length/size FILTER BED ❑ Distance to res : Well, - Foundationroperty Line i SEEPAGE PITS l I Depth Sire Nit{nber I SUMPS ance to nearest: Well Foundation Property tine 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 i rules and regulations of the San Joaquin Local Health District. i 1 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 1 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- 7he.ppsli.a ofCalifor 'a."st all all r quir ins ctr s. Cp late drawing on verse side.Title: / Date: FOR DEPARTMENT USE ONLY � Application Accepted by Date sr —1,64�nArea Pit or Grout Inspection by � Date Final Inspection by 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH' RECEIVED BY DATE (P'ERRMIT'NO. +.EH 13-241REV.I/H5) EH 14-26 fJ I