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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT FILE 1601 E. HAZELTON AVE., STOCKTON, CA Copy 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. 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 City Lot Size - PM fsf,/ 1 �r�/1.� 1 C_ Address , r Owner's Name _ _ �S�y C✓ S Contractor l f Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTAN EAREST: SEPTIC TANK- SEWER LINES DI FLD. PROP. LINE UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF ROBLEM AREA . C UCTEON SPECIFICATIONS El Industrial fl Open Bottom Q Manteca a. of Well Excavation Dia. of Well Casing Pi ❑ Domestic/Private D Gravel Pack cy Type of Casing Specifications Public ❑ Other ❑ Dena Depth of Gro.[ Seal of Grout- 1`1 I I Irrigation _.App Depth l ! Eastern Surface Seal Installed by Repair Work Done ❑ Ty Pump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing Material Itop 50') v' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION i I DESTRUCTIOPW4,fNo septic system permitted if public sewer is tt available within 200 feet.) Installation will serve: Residence—1 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 LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED P ❑ Distance"to nearest: Well' Foundation Property Line it SEEPAGE PITS I I Depth #t Size Number SUMPS ❑ Distance.to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 3 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 cbmpensation laws of California."Contractors.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 California." The applicant must II f all a fired irf3pections. C plate drawing on reverse side. q Signed X^ _ . .�/ �r Title: ✓N Date: I FOR DEPARTMENT USE ONLY Application Accepted by _ Date L2 Area Pit or Gr ut Inspect y Date Final Inspection by 0L-0 ��e `_41 AN'-w�S Data J'CKr- (G r.�re _ N:,t'5.1+-2 04S,e Yoa_4 �CfreO +�l Additional Comments: 4 -9 ❑ Stk 466-6781 ❑ Lodi 369-3621 It Manteca 823-7104 ❑ Tracy 835-6385 .3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 3iz4r4a [�.�� s s iJ SSC re� [ CC INFO MOUNT DUE1 AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'No, C f + EH 3.24(REV.t/ 5) �� Je� EH 14-28 3, S