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low '" 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 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. ` f Job Address f 07 C/f q RA k0-rlT CityV 7—r— &) Lot Size /66c/ _-FfM � Owner's Name 6 ` � t•�`-' �`-�'" i-' ��— (gless Phone Contractor Address �lJ� ��ld�I lVer L ense No. ` `" Phone . TYPE OF WELL/PUMP: k NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ t PUMP INSTALLAT SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPT TANK �� SEWER LINES DISPOSAL FLD. PROP:LINE FOtiNKATION AGRICULTURE WELL OTHER WELL�`PITS/SUMPS INTENDED USE "TYPc OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC T NJV ' 1-11 ncyastrial ❑ Op Bottom ❑ Manteca Dia. of Well Excav tion Dia. of Well Casing �� q .stic/Private ravel Pack ❑ Trac Type of Casing Specifications l� Public f Other elta Depth of Grout Seal Type of Grout A I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material (top 50'1 _--- Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i 1 DESTRUCTION I I (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: f Well Foundation-'/y Property Line d LEACHING LINE ❑ No, & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS '^'°'l?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 certifies the following:'-1 certify that in the pertOrman a of the work for which this permit is issued. I shall employ persons subject to workman's compensa- tion laws of California. The applicI re ns. omplete drawing Orn r�v e �� Date: sid J� Signed X Title: V �l V�� / FOR DEPARTMENT USE ONLY l Application Accepted by Date I I � 7 Area crci Pit or Grout,lns tion by - Date D Final Inspection by Date � -A f Additional Comments: rD 6f1/l ❑ Stk 466-6781 ❑ Lodi 369411 ❑Aflenteca 823-71 -1"❑ racy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ICK NFO AMOUNT DUE AMOUNT.REM ITT ED CASH RECEIVED 13Y DATE PERMIT'NO, + EH 13-24(REV.t/k5) EH 14-28