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4 APPLICATION FOR PERMIT ~ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Distrii/c��t.f//{� Q �( , 4 -1 1 �C ?1– _ L' Lot Size 55 I 1L PM Job Address City �'1 Owner's Name 411& A4 r�� _ Address Phone Contractor dress 11(6 !r dtDl License No.2-Z(j2_ `7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [3 PUMP INSTALLAT N ❑ STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER ES DISPOSAL FLD. ` PROP. LINE FOUNDATION AGR LTURE WELL OTHER WELL PITS/SUMPS INTENDER USE TYPE OF WELL P BL AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ nteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private 1-1GravelPack Trac Type of Casing Specifications f 1 Public F] Other ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation —Approx. De th I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ESTRUCTION f I (No septic system permitted if public sewer is K— 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: Well Foundation Property Line �s LEACHING LINE ❑ No. & Length of lines Total length/size (0 FILTER BED ❑ Distance to nearest: Well Foundation Property Line s 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: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applica t t c I or all req u' i ions. Complete drawing o erse side. Signed k6s Z Title: h Date: ` FOR DEPARTMENT USE ONLY Application Accepted by _�� _ �Z Date ,. Area Pit or Grout Inspection by f, ! D to Final Inspection by Date Additional Comments: GWrrn ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO AS + EH 13.241 REV.IyR5) 3 S �� EH 1426