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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 M h 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 Sen Joaquin Local Health District. 'fes �+ / Job Address �� ref-E � 3�� ✓(, 'f rt j� _ City i H- Lot Size PM Owner's Name -Gi-L l�/[1, �LL 1� Address 1247 l� �� 104,11 4,11 Phone _7316 Contractor � O !� ddress _� �W f` ( D License,No. C )' L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT X DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ rnrnOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDr�vPROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELLWy�. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati Dia. of Well Casing!! Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications iPt7 F L1Public C1Other [-] Delta Depth of Grout Seal Type of Grout w ❑ Irrigation XApprox. Depth Y41fiestern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �} Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 D"9 Type/Mfg Capacity No. Compartments t-+I PKG. TREATMENT PLT. ❑ Method of Disposal pIl Distance to nearest: Well Foundation Property Line �� LEACHING LINE ❑ No. & Length of lines Total length/size ,s FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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:"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 Californ' The applicant at call for all u' in ctions. Complete drawing on r erse�siidd Signed Title: `�•� _ Date: FO B�PARTMENT USE ONLY Application Accepted by Date 4k Area Pit or6g2t Inspection by c� ate.-�v Final Inspection by Date Additional Comments: T Z�tl_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-63M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. + EH13-241REV.tie51 76 2 u/ EH tF28 sss��