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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 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. Job Address City at Size f PM Owner's Name Q L.f Vk A-' !W 1ePyZAddress 16(a �s ✓_ . -51k,,/.Phone .--- Contractor — Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT( ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A NSTRUCTION SPECIFICATIONS C1 Industrial EJ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private CI Gravel Pack ❑ Tr Ty of Casing Specifications FI Public Cl Other elta Depth o rout Seal Type of Grout I I lrrigalion __Approxi pep I I Eastern Surface Sea stalled by _ Repair Work Done D Type of Pump H.P. State Work Done Well Destruction C] Weil Dia Sealing Material (top 50') Depth I Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f 1. REPAIR/ADDITION 1.1 DESTRUCTION (No septic system permitted if public sewer is.,. available within 200 feet-) R Installation will serve: Residence Commercial_ Other 'fes t 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 6 LEACHING LINE ❑ No. & Length of Eines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ( SEEPAGE PITS I I Depth I 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 Dliltrict. 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 became subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature I 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 must call for all required inspections. Complete drawing on reverse side. Signed X {- Title: r,ci �- Date: `V- L�✓ 1 FOR DEPARTMENT USE ONLY i Application Accepted by li, Date Z Araa ;2' J Pit or Grout Inspection by I%N y1 Date Final Inspection by Date44 Additional Comments: Q ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 Y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 FEE INFO AMOUNT DUE -A7M/ODUNTT REMITTED CK CASH NO.RECEIVED BY DATE r� j{]P�ERMIT']NOS/ +.EH 13.21(REV.I?'15) . s00JJ d y (/ X34- , Ere 14-26 V C! O /✓ 1