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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 l 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. ^�,1� � Job Address ©`z o A dA_T City /F ` �`'`+ Lot Size 1o0 'X S 0 / PM Owner's Name / / SRA/ h O Address _ A�-2 O ••'?V 7_ Phone 204•-'7sZ�6(7]6 Contractor � lF Address a2o�0 fl 47 _lit License No. Phone .3 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEWER LINES DISPOSAL FLD. ' FOUNDATION ULTURE WELL ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROS �_D�a =Excl ON SPECIFICATIONS R, ❑ Industrial ❑ Open Botto Manteca . of avatio �M3 of Well Casing ❑ Domestic/Private a Pack ❑ Tracy Type of Casing cations ('1 Public Cher ❑ Delta Depth of Grout Seal Grout I I Irrigation _-Approx. Depth I 1 Eastern Surface Seal Installed by - nV Repair Work Done 0 Type of Pump H.P. State Work Done_ �1 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l I 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well-" '^ Foundation Property Line SEEPAGE PITS f I Depth Size Number r SUMPS 0 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 Wofmance 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 m st a for all re wired=Spectionomplete drawing on reverse side. p / �j 4 ,r/ ,� Title: L A/0Z O� PCU , Date: Signed X:_kf/ FOR DEPARTMENT USE ONLY Application Accepted by !2� Date Area Pit or Grout Inspection y Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO �^CA(SH1 f +.EH 13-241pEV.1/851 SSi C�� EH 1028