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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA \\ Telephone (209) 466-6781 \�t\ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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. 9 Job Address �� i�IfJ 9 U��►�1 , A' _ City c Lot Size PM Owner's Name g U1s�e--1 + _ACI Address Phone Contractor Address C%P YOK License No. VPhone V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO N REST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FO AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBL€ CON 10N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. a ava"on Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications \ Public (� Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation prox. Depth l I Eastern Surface Seal Installed by V'NRepair Work Done Type of Pump H.P, State Work Done Well on ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 HEPAIRIADDITION I I DESTRUCTION")<(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other s Number of living units: Number of bedrooms e4 Character of soil to a depth of 3 feet: Water table depth v CL SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthtsize z FILTER BED ❑ Distance to nearest: Well Foundation Property Line M SEEPAGE PITS i I Depth Size Number ( SUMPS Ll Distance to nearest: Well Foundation Property Line d 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 �l) 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: "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." The applicant t call for all q d inspections. Complete drawing on r se si e. Signed Title: Date: . _�C — FOR DEPARTMENT USE ONLY Application Accepted by •- _.. Date � �-� Area Pit or Grout Inspection Date Final Inspectiop by /} 1Date Additional Comments: J-0-Y7 7-t-L �, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mentecs 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 I AJO-+c r Cl�.t� 14 r. l"- "L, n G v v,-.1-J n U f Q t/Er Lljll *�h 6 C�raj i�-�c'"�� I INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 6Y DATE PERMIT'NO. +.EH 13-24 IHEV.1/H51 EH 14-26