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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 District. Job Address 2-y�_��, /! ' �_.,_,.,___._,____ City j Lot Size PM Owner's Name iK/ Address 7310 r!(ifD7L Am 14i ze.-dw Q Phone Contracto Address 74 �4&__ License No.3.29..Z46. Phone TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI INOTHER El TO NEAREST: SEPTIC TANK SEWER LES DISPOSAL FCD. PROP. LINE FOUNDATION AGRICULTUREL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom 11Mant Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Packacy Type of Casing Specifications (`l Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I f Irrigation __..APer . epth I I Eastern Surface Seal installed by _ Repair Work Done ❑ T of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50'1:::�f S Depth Filler Material (Below 501 }� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial_ Other Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth Z' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Vr No. & Length of lines I- 4 D ILtTotal length/size 4,9 L,41 � FILTER BED ❑ Distance to nearest: Well oea Foundation 0 1 t Property Line .. __ SEEPAGE PITS l Depth kt Size _T/.tt Number f SUMPS Cl Distance to nearest: Well CSO Foundation 0 Property Line_ ]law, ,nd DISPOSAL PONDS ❑ I hereby certify that I have prepared this a lication and that the work will be done in accordance with San Joaquin county ordinances, sta rules and regulations of the San Joaquin Mcal Health DiMrict. Horne 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, 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 � rd �• ►� o Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r Area l Pit or Grout Inspection by Date Final Inspection by �� i Date Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24{q EV.r/n sl �aC�/' 1 11 EH 14-26 C> J 9 11 a