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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 `' i6 City � %Lot Size PM ��v� (E �{-�AI� a ( 5 f2l�r�E V&2-72-747 Owner's Name � 1i r L ddress S �-. AVC--� Phone Contractor £ Address License No. Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL P BLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma a' W Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ acy Type of Casing Specifications I'i Public ❑ Other Delta Depth of Grout Seai Type of Grout --- s i Irrigation _..Approx. Dep I Eastern riaca Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Notarial (Below 50'} I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTIO I Wo septic system permitted if public sewer is vailable 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. ❑ t Method of Disposal Distance to nearest: Well'- Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I 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 h 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 Calif ia.- I The applicant ust c I for all req re ins ctions. Complete drawing on reverse side. f Signed Title: OwweR-�- Date: F�EP�ARTM�NT USE ONLY Application Accepted by {{ DateAii:L� rea Pit or Grout Inspection by Date Final Inspe ian by Date Additional Comments: AA ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ 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 PERMIT'NO. + EH 13-241REV.1/851 EH 14-28 �..J�r �� 15057