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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. F i Job Address r � Lot Size PM Owner's Name (_.(L(TJ� j 7 f City J� y, / - �d Address L i -+ 1. / �Al�/ n Phone J rc F.2 h ._ / J f Contractor -�A, r �� Address 124 '/ , - _f- TYPE OF WELL/PUMP; License No/6 Phone3 NEW WELL [J WELL R_E_PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION "0-1 SYSTEM REPAIR C' DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES — PROP DISPOSAL FLD, \ FOUNDATION AGRICULTURE WELL . LINE INTENDED USE OTHER WELL PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 6 Open Bottom If Manteca Dia. of Well Excavation Public domestic/Private CI Pack ElTrac Dia. of Well Casing f`l V Type of Casing Cl Other Cl DeltaSpecifications I 1 Irrigation De —.-Apth of Grout Seal Type of Grout pprox.;Dep h I 1 Eastern Surface Seal Installed by Repair Work Done 0-. Type of Pump, y H.P. --L State Work Done Well Destruction ❑ . Well Diameter Sealing Material (top 50') pepfF- - ler Matt rial`(8iilow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I-1 REPAIRJADDITION i I DESTRUCTION I I -40 septic system permitted it public sewer is Installation will serve: Residence�� `, available within 200 feet.) `- Commercial� Other -Numbe'r`of living units: • Numb&.of`bedrooms I Character of soil'to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. El Capacity. No. Compartments Method of Disposal Distance to nearest: Well Foundation j r ��_ Property Line r LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to'nearest: Well` Total length/size Foundation Property Line SEEPAGE PITS f I Depth Size i C SUMPS 1-1Distanceto nearest: Well Number DISPOSAL PONDS F] Foundation Property Line i 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. I 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: "I certify that in the performance of the work for which this permit is issued, I shall employ pe rs tion laws of California." ons subject to workman's compansa q� The applicant mustrG�ll f all re uu ins q inspections. mplete-drawing on reverse side. -, Signed � Date: ' FOR DEPARTMENT USE ONLY Application Accepted by� '�'�[ i .Date_ Pit or Grout inspection by Area Date� Final Inspection by Additional Comments: t Date i ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009 Stk., CA 95203 1. FEE AMOUNT DUE CK INFO � AMOUNT REMITTED PERMIT'NO. + EH 124 IfiEV.riN51 CASH RECEIVED BY DATE --I :ju C3� EH 144.28