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APPLICATION FOR PERMIT Vie SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 ,'04;�4z City " Lot Size PM Owner's Name AddressPhone ; —- " Ir rr+ � �/'i Phon r' +,,• , •a* Address ry License fJo. Gantractor , TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'S SYSTEM REPAIR $ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1NTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industria! ❑ Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing WDomestic/Private ravel Pack ❑ Tracy Type of Casing Specification F- I"r Public CI Other ❑ Delta Depth of Grout Seal - Type of Grout-.0-A. 1 w 13 Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump �_ H.P. State Work Done_ } Weil Destruction D. Well Diameter Sealing Materi I (top 50') Depth Filler Material (Below 501 TYPE OF,SEPTIC WORK: NEW IN Ll REPAIRIADDITION I I DESTRUCTION I 1 Wo septic system permitted if public sewer is f. available within 200 feet.I , Installation will serve: Residence Commercial Other Number of Living units: Number of bedrooms .P Character of sail to a depth of 3 feet: Water iable depth SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments PKG. TREATMENT PLT. 0 Method.of Disposal .' Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ No. & Length of lines Total iength/size x FILTER BED ElDistance to pea- rest:' Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property 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 Di§trict. Horne 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 taws 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 must gall Tb� al quired inspections. ��romplate drawing on reverse side, Signedr, / ✓�"�/ fj napyo.+fitle: FOR DEPARTMENT USE ONLY Application Accepted by Date911 Area �� Pit or Grout Inspection by Date Finer Inspection by Data Additional Comments: ' ❑ Stk 466-6781 A94 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED.BY DATE PERMIT'NO. INFO CASH +.EH13-24 1REv.1/K 51 ©.� i� ;t,1 EH 14.26 - —---— — ---