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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. Yhis 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. ` t f_j 2-C C3—d—] { le Job Address o-ohar City Lot Size PM r Owner's Name A dress "`l " -`s �_ P one i st Contractor t \ Address 4�T ( �� Li nse No. Phone TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR C7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S < ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavatio Dia.'of Well Casing t ❑ Domestic/Private `ravel Pack ❑ Tracy Type of Casing --nnom� Specifications m Public F1 Other F Delta Depth of Grout Seal _ �r2!/� Type of*Grout 1 1 Irrigation �t OApprox Depth I I Eastern Surface Seal installed by l� r 1 Repair Work Done ❑ Type of Pump _99H.P. State Work Done _ Well Desiructinn ❑` .D pt Diame ``r . SealFillerng Mater ial rl(Below 50') Li I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION l I DESTRUCTION I I (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 t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ��_. No. Compartments PKG, TREATMENT PLT. ❑ ; .d Method of Disposal U, Distance to nearest: Wel Foundation Property_Line '� Q LEACHING LINE ❑ No. & Length of lines 14bt, 10INi Total length/size FILTER BED Distance. o nearest: Weil } Fou dation,-- -- Property Line -- _: SEEPAGE PITS4 I l Depth , Size Number SUMPS C7 Distance to nearest: WeII "' Foundation Property Line I —DISPOSAL•PONDS— CJ 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. I 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 followi g: "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 Calif ni , #!✓'i#.`dA j*- k The applicant riIL required inspections. Complete drawing onr er side. / I Signed. Title: Date: FOR DEPARTMENT 9SE ONLY 4 (� t Application Accepted by tiAwain Date u Area 7 2XwiER r - Pit or rout spection by Date Final Inspection by/O. Date Additional Comments: ❑,Stk 466-6781 `❑ Lodi 369-3621Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Hea I:�Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. _ INFO CASH Q1 /y + EH 13-24(REV.1/H 51 3S-0 � ( ' ,� P• �(7—(�f 6 EH 14-2e AAA CJ 4