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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 Coun Ordinance No.549 for sewage or No. 1862 for well/pump and the RUles and Regulations of the San Joaquin Local Health District. S(D©(P PpgG(\11 C� ' Job Address �£ k.o1�A�C `111 lL �1'A1n .�— City Lot Size PM k © t ( Address Phone Owner's Name ,l: .4Q.(l�1Pt,4Y-- Address�+_ "`^'r� S� b License No.4-7ZSZ ��Pho``ne''116&—� e� 1 -55 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONOTHER �K PUMP INSTALLATION 11 SYSTEM REPAIR ❑ 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 Dia. of Well Casing ❑ Open Bottom O Manteca Dia. of Well Excavation ❑ Industrial Pe Specifications � ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— l,OA'fti� Gout ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type ofrI "C.cCSb� ❑ Irrigation --Approx. Depth ❑ Eastem Surface Seal Installed by Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 51 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailabPelwithin e200 feetm per tted if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: well Foundation P rt1' Total length/size Distance LEACHING LINE C3 & Length lines Property Line FILTER BED ❑ Distance to nearest: est: Wer Foundation Number SEEPAGE PITS ❑ Depth Size Pro Line SUMPS ❑ Distance to nearest: Well Foundation Peru' DISPOSAL PONDS ❑ 1 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 compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:111 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 'tor is." The applic t m s c It or a I wired inspegtions. Complete drawinon lyfse side (� S Signed rde � LJ1 soy- "I Date: A T USE ONLY rea Date Application Accepted b Date Dow - Final Inspection by d 1ZCL� Pk or Grout lnspec y � Additional Comment 835-6,385 [I Stk 466-6781 ❑ Lodi 369- ❑ Man t 823-7104 ❑ T Y Applicant- Return all copies to: Environmental Health Pemfd/Services 1601 E. Hazelton Ave., P.0 , Stk., CA 95201 FEE K RECEIVED BY DATE PEflM1T'-NO. INFO AMOUNT DUE AMOUNT REMITTED EH 1124 IREV.1/05) �. IiI I �S EH 1L29 (,C