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`- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q091 466-6781 i PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. y Job Address _.�23q Rzjkn.), � _liven ae_ City _'vim Lot Size PM L11 y Owner's Name Cei- &_I ee 14�dres�s n al�f rs &.Phone ,\ l � J lJ Contractor ��! Address 223% 0 /rrG�G��[ icense No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI DISPOSAL FLD. PROP. LINE FOUNDATION CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE T PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open B m ❑ Manteca Dla. anon Dia. of Well Casing ❑ Domestic/Private ❑ Gr PackF Q Tracy Type of Casing Specifications C 1 Public f ther 71-Delta Depth of Grout Seat Type of Grout I Irrigation Approxi Depth I I Eastern Surface Seal Installed by _ r - Repair Work Done ❑ Type of Pump rJJ H,P. State Work Done Rr �Y Well Destruction Ll Well Diameter Sealing Material Itop 501 Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION i 1 (No septic system permitted if public sewer is iit available within 200 feet.) Installation will serve: Residence? Commefcia[_" Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ElType/Mfg Capacity No- Compartments PKG. TREATMENT PLT. ❑ r'. ..r- l s Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total'iength/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well - Foundation- Property.Line DISPOSAL PONDS ❑ I 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 Di1trict. 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 call r all re wired ' coons, Co p to drawing on reverse side. x Signed X p Title: Wh H Date: ! FOR DEPARTMENT USE ONLY Application Accepted by - Date U Area Pit or Grout Inspection Date r R�Y Final Inspection by Y Date Additional Comments. AC 0(/ G l ! f G CC rt p ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 C1ASH RECEIVED BY DATE PEfiMIT'NO, EH 11 EH 13-24 -21fREV.i/n5Y