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2 APPLICATION FOR PERMIT `S .? SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. .G� 4-0 � U hJ�l� City NJ Lot Size PM Job Address _ r Owner's Name lyt e'W IN Address { Phone `0 4 ~ Contractor Address W4- V W License No. Phone TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ ;a PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open ❑ Manteca Dia. of Well Excavation ia. of Well Casing Alp Domestic/Private –fes Gravel Pack ❑ ra Type of Specifications li ❑ Public ❑ Other ❑ Delta o 'PU Type of Grout ❑ Irrigation ---Approx. Depth n Surface Seal Installed by Repair Work Done ❑ Type H.P. State Work Done Well Destruction - ell Diameter Sealing Material (top 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence-1– Commercial_ .Other . ,. Number of living uni s*� Number of bedrooms AU-3 ..,rr`w�rr. ,;- Character of soil to a depth of 3 feet: 0.Water table depth I SEPTIC TANK TypelMfg -1f Capacity_— No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal � Distance to nearest: Well Foundation_ l 0 Property Line_3_S_L_ LEACHING LINE ❑ No. & Length of lines 3 �a Total length/size1. 0 i FILTER BED ❑ Distance to nearest: Well��- Foundation /a� Property Line SEEPAGE PITS ❑ ;Depth Size Number a r t SUMPS ❑ Distance to nearest: Well Foundation Property Line Is �1111100_ ON 00"111". DISPOSAL PONDS ❑ I - I hereby certify that I have pre-pared 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, 1 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, F certifies the following: "1 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.; k, r The appli aht t call for all re"insptctiok Complete drawing on reverse side. Signed •l Title: bate: 67– FOR DEPARTMENT USE ONLY ° Application Accepted b Date Area Q Pit or Grout Inspect o y Date f If ' Final Inspection by '"""^"� Date ' Additional Comments, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M , Applicant k Return aA copies to- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. r FEE ' � INFO + EH 13-24(REV.1/e 51 EH 14-28