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r ri ,is -° APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA N� ki rz-o- Telephone 12091'466-6781 N�► l,_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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 ec III City Lot Size PM I Owner's Nam 12Address J :gc"r o g!:7 Phone �+ nC��Ai� 'f I_`� Contractor;X, (T,') t �UfUAddress �f 7�. � License N6 &Q Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM R AIR El OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF.WELL PROBL AREA CON RUCTION SPECIFICATIONS ❑ Industrial Fl Open Bottom ❑ Monte Di . of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy ype of Casing Specifications k 11 Public [] Other ❑ Delta Depth of Grout Seal Type of Grout _ [ 1 1 Irrigation �.-Apprax Depth l I Eastern Su pe Seal installed by _ Repair Work Done ❑ Type of Pump .P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO4ONf(No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth• -SEPTIC TANK ElType/Mfg Capacity No. Compartments " PKG. TREATMENT PLT. ❑ .5 a Method of Disposal Y.. t 4 Di9tance to nearest: Well Foundation Property Line T3 LEACHING LINE ❑ No. & Length of lines Total length/size— FILTER ength/size FILTER BED ❑ Distarice to nealrest: Well Foundation Property line 4 SEEPAGE PITS I I Depth f Size Number SUMPS L Distance to,nearest:---Well---Foun'da'tion f"+ i Property Line i 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. t Home owner or licensed agent's signature cert ifies'thelfollowing: "I certify that in the performance of the work for which this permit is.issued, l 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." :+ x t t The applican st cell or all requir Usctions,. omplate drawing on reverse side. c t Signed X """' `"Title:4(� /'� __ Date: i E A SE_ ONLY., = Application Accepted by f Date-M [ rea v Pit or Grout-inspection by ""`,�r q��"�""' "Ser " /�y," F5''ghlnspection by DatAdditional Comments: U F1 t r t I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-645 X Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE MOUNT REMITTED RECEIVED BY DATE PERMIT'NO. I + EH11-2a3-21(REV. i N s) 1 l f w n1 �/1 7 JJ�7_3rf"C� EH 1 -•�►'J^-�