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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone 12091 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. 2'OR I CUM Job Address s City L 11112 15 Lot Size PM Owner's Name kAWAJ E Z2n "L ,-S Address .SAME Phone Contractor_�l d l&VO > Address Itf L 7" 411 License No. 41C Phone 6X-3'?7 _ TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ £DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f• ❑ Industrial ❑ Open Bottom © Manteca Dia. of Weil Excavation ilia. of Weil Casing VCI Domestic/Private ❑ Gravel Pack ❑ Trac T ,.. y ype of Casing -�'* Specifications` ` !❑ Publict Cl Other ❑ Delta Depth of Grout Seal �' Type of Grout'-.— I rout _I lrriyation :y, Approx.`Depth I I Eastern Surface Seal Installod,by 1 Repair Work Done ❑ Type of Pump}..' H.P. t State Work Done " Sealing Material (top 50'1 #Well Destruction D Well Diameter er^s t '. Depth '� Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION DESTRUCTION-I-I-Wo septic system permitted if public sewer is (� 3r Ali j` available within 200 feet.► f V Installation will serve: Residence_r/ Commercial_ Other Numb�r of living units: ,_,Number�of bedrooms � Character of soil to a depth of 3.feat: Li Water table depth -SEPTIC TANK ❑ Type/Mfg Capacity L----=NO.-Compartme(its f PKG. TREATMENT PLT. ❑ r ; i, - '"r Method of Disposala.. Distance to nearest: Well Foundation Property Line � • k tit - ( , ! . , LEACHING LINE No. & Length of lines — i�..e r . Total length/size ' FILTER BED ❑ Distance to nearest: Well SQ r �F`` Foundation 3B Property'Line SEEPAGE PITS _ I Depth Y�r Size__a�5 " Number I j �1 SUMPS LI Distance to nearest: Well /O 0 , Foundation 40 Property Line DISPOSAL PONDS ❑' +�_ r T j I hereby certify that I have prepared this application and"tK&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. ; 1 r A Home owner or licensed agent's sigriature,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." r r The applicant must call for al required ins ctions. Complete drawing on reverse side. '` Signed X_ Title: Date: _7 P-2 FOR DEPARTMENT USE ONLY �� Application Accepted by v " Alen. Date Area Pit or Grout Ins tion by Data w �inal?Inspectionby �a.. Date a- (1 Additional Comment ❑ Stk 466-6781 Lodi 369-3621 0 Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. �+ EH 13-241REV.F/N5) C)• I� rR')•,_ ,��/_�- EH 14-2e