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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 C City �r oC�.2 Lot Size PM Owner's Name ifto h!A M.-A CID-I'`�if Ad Address 1110 C1 b-a,4(% 157--S c eT,.a.t Phone 14 q -os Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ri► POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications ❑ Public ❑ Other X7 Delta to the of Grout Seal Type of Grout ❑ Irrigation _Approx. epthh ❑ Eastern surface Seat-installed by Repair Work Done ❑ Type of.PGmp H.P. F State Work Done Well Destruction ❑ -Wtal Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 i': TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION E DESTRUCTION (No!septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: g Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments lr1 PKG. TREATMENT PLT. - – Method of Disposal Distant Barest: Well Foundatio Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to ne t: Well Foundati 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 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." The applicant must call for all required inspections. Complete drawing an reverse side. Signed Title: Date: FO DEPARTMENT USE ONLY Application Accepted b Date 2z Area Pit or Grout Inspection y ate Final Inspection by_ Date Additional Comments - o ❑ 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 966201 FEE AMOUNT DUE AMOUNT REMITTED K# RECEIVED BY DATE PERMIT`No. INFO + EH 241REV.t/651 �� W EH 1428 /