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APPLICATION FOR PERMIT aAN JOAQUIN LOCAL HEALTH DISTRI 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. Job Address �in C f City S415CL+c n Lot Size PM Owner's Name 20 y 4%4 wr-CCI""IllEidress Sar,PP7 if_ Phone Contractor Address S-fa r+ Z-R License No. Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E] DESTRUCTION ❑ /� PUMP INSTALLATION El SYSTEM REPAIR 7-1 OTHER, JO 1.I 09j't DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA ON AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE J L PROBLE AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma eca Dia. of Well Excavation Dia. of Well Casing ❑/Domestic/ Nate ❑ Gravel Pack ❑ T acy _T- t� ng Specifications ,v�f"a WV_1 f f- Ot�er ❑ DeltaDepty4 Grout eal � y r of Grout�ta[� [a�rS �//��I I LLL_Approx. Depth I Eastern -8err '' � �Rene ❑ Type of Pump H.P. State Work DoneWn ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public wer is available within 200 feet.) G Installation will serve: Residence_ Commercial _ er Number of living units: Number of be( \ 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 � Di nce to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & ngth of lines Total leng Ize FILTER BED ❑ D' ance to nearest: Well Foundation Property Line N SEEPAGE PITS I I Depth Size Number perty SUMPS D Di nce to nearest: Well Foundation Line DISPOSAL PONDS ❑ 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. 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 persons subject to workman's compensa- tion laws of California." The applicant mu for all required ' cti Complete drawing on reverse side. Signed X Title: Col all E.0 " Date �� FO�DEPARTMENT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection by Dat© Final Inspection by Date 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. Hazelton Ave., P.O. Box 2009, S:k., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK ¢ RECEIVED BY DATE PERMIT NO. INFO �7 G /may CASH9 . EH 13-24(REV.riNSr X / 777, EH 144-28