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APPLICATION FOR PERMIT uAn� fCvv SAN JOAQUIN LOCAL HEALTH DISTRICT w > 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,eby 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. f � '�` Job Address �Ah f— -��/17) wUr r By',P_CEL- City ^--'rk4J-4— Lot Size PM Owner's Name r bEiE LISL-LJ a4S 0 dress �� '� _ y Phone Contractor WJ$LT�8U _(n l`t Address 10 License No.4_3DQ_-1-Phone I 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 FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ClJ C Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C Gravel Pack G Tracy Type of Casing Specifications ("1 Public C Other M Delta Depth of Grout Seal Type of Grout I Irrigation —_-Approx- Depth I ! Eastern Surface Seal Installed by _ Repair Work Done G Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth _ Filler Material(Below 501 _. TYPE OF SEPTIC WORK: NEW INSTALLATION : PAIR/ADDITION ( I DESTRUCTION t I (No septic system permitted if public sewer is ;o^ r. available within 200 feet.) s Installation will serve: flesi nce�mmercial Other Number of riving units: Number of bedrooms r- r i Character of soil to a depth of 3 feet:_A-sno-� Water table depth � � , SEPTIC TANK r� e/Mfg. C_0. f`r=t;=— " Capaety jlaccs 1 No. Compartments PKG. TREATMENT PLT.❑ r Method of Disposal y} l Distance to nearest:_ Well Foundation r J Q Property Line, t LEACHING LINE +, o._Y & Length of lines 3__^ Total lengthlsize� ti FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 11 4 ' epth _ Size.. Number SUMPS L� Distance to nearest: Well _._-Foundation ZJ 5 Property Line DISPOSAL PONDS ❑ �. I hereby certify that I have prepared this application and that the work will.be done ih,, ccordance with San Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. r 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 taws of California."Contractor's hiring or sub-contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued`I shall employ persons subject to workman's compensa tion California. r N The applicant call for I�� ,d pec i , mplete drawing o everse si e. Signed _ Title: Date: f FOR DEPARTMENT USE ONLY 'Application Accepted by CM C"g), Date rea Pit or Grout Inspection by Date Final Inspection by_, Date l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.Q. Box 2409, Stk., CA 95201 FEE11 INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO- FF ^7 I . EH13.24(REV.,i H s, EH 14-26