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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON 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 I 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 Al Local Health District. }y Job Address City � Lot Size � b K 360 PM } d Owner's Name - _� 4-1W,2dQ 124-446P•Address _ Phone Contractor L Fu t a Address License No. 7 Phone 9 `T TYPE 0 ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i i PUMP INSTALLATION ElSYSTEM REPAIR I-) OTHER ❑ DISTANCE TO NEAREST: 'SEPTI SEWER LINES DISPOSAL FLD, PROP. LINE Y ` f FOUNDATION. ULTURE WELL OTHER WELL ° PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS II ❑ Industrial El-Open-Bottom-1-1 Manteca-�-�'- . ofDia-of-Well-Ex'c we Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifrcations ❑ Public ❑ Other ❑ Delta Depth of Grout Seal of Grout ❑ Irrigation =llpproxDepth El Eastern, 2Surface Seal Installed by i Repair Work Done ❑ Type of Pump � H P.- 4,,f `State Work Done Well Destruction El Well Diameter Sealing Material {top 50'1 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is "y V' -"""�W"" `" "' "" " "' �""' _`-a`vailabWwithin 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/MfgCapaci t•L436> No. CornpprtTqntsL. PKG. TREATMENT PLT. ❑ t e3 r ; Method of Disposal Distance to nearest: Well. ? Foundation ► Property Line a LEACHING LINE L1 No. & Lengtof lines _ LL Tota length/size a I FILTER BED Distance toineares�� El Well Z Foundation party E = SEEPAGE PITS ❑ Depth } -Size I Number SUMPS ❑ Distance to nearest: Well Foundation t Property Line s i DISPOSAL PONDS ❑ ' `Y ------------- I hereby certify that I have prepared this application and that the work will be•done in accordance with-tan Joaquin county ordinances, state laws,'and rules and regulations of the San Joaquin Local Health District. .v' Home owner or licensed agent's signature certifies the following: "I certify that-in The_performan e,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 Califomia."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 persons subject to workman's compensa- tion laws of California." r ?!employ The applicant must call for all requited inspectiods. Complete drawing on.reverse side. Signed s Title: — .._.1rrf�C. � '. Date: f { OR DEPARTMENT USE ONLY Application Accepted by Date d-7'd 2 Area go ;7:�Y ?? Pit or Grout Inspection by Date Final Inspection by Date F � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362.1, ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant-Return all copies to: Environmental,Health Permit/Services 1601 E. Hazelton Ave.; P.O. Box.2009, Stk., CA 95201 r � FEE �. INFO AMOUNT DUE l AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. + EH 1324{REV,,tW�s 51w-.• - EH 1428 �