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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-Ml 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _- 14 J 7 1 A)4 —_ City J �SicTf�p% Lot Size_ _ PM Owner's Name _.V41-014-41k may__ k . Address _ Phone Contractor , _Address,- 72 2 2,Sgra �i► License No.�/ /�[-2,Cj&,Jy_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR L OTHER C 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 Industrial = Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l_: Domestic/Private n Gravel Pack — ❑Tracy Type of Casing- _ Specifications C Public ❑ Other ❑ Delta Depth of Grout Seel Type of Grout I)Irrigation i ---Approx. Depth ❑ Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction C) Well Diameter Sealing Material(top 50") ' Depth__ 1 Fillir Material(Below 501 _ TYPE OF SEPTIC WORK: ,NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION Pmo septic system permitted If public sewer is —r available within 200 feet.) ` Installation will serve: Residence_ Commercial_, Other Y Number of living units: _._ Number of bedrooms Character of soil to a depth of'3 feet: L' Water table depth SEPTIC TANK _ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.C: /.- Method of Disposal Distance to nearest: Well Foundation Prp' petty Line LEACHING LINE ❑ No. & Length of lines i _ Total length/size FILTER BED ( ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS i ❑ Depth Size Number I SUMPS ❑ Distance to nearest: Well__ Foundation Property Line DISPOSAL PONDS 1 ❑ I hereby certify that I have'pirepared'this'ipplication 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:"I certify that In the performance of the work for which this permit is issued,1 shell employ persons subjsat to workmen's eompense- tion laws of California." . f The appGeant must call for all wired in req spections. Complete drawing on reverse aide. ` 'I Signed Title: __Suar�/A�Tia�.�r�,� ._.. Date: !-9f f FOR DEPARTMENT USE ONLY /,, c ✓/� Application Accepted by Date v I J Area �! Pit or Grout Inspection by Date Finaln by pate OwlAdditional Comments: _ G�1 a16 4616-6761 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 83548386 Applicant - Return all copies to: Environmental Health Permit/Services 11301 E. Hazehon Ave., P.O. Box 2WO, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITMD RECEIVED BY DATE PERMIT-NO.INFO . EN 1324 IREv %,ant EH 142e S� 1N 5 g5-blas