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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1501 E. HAZEL T ON AVE.; STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES.1 YEAR FROM DATE ISSUED 3 (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. 'C , Job Address � :7 City 'L-Lot Size.ZZ w6l�KPM Owner's Nam �,.ZFy1� /7� Address Phone � z w 1 o�fLd e tContractor Address �[ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ t DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Domestic/Private ❑ Grave4 Pack ` p,zracy Type of Casing _ ' g - Specifications ❑ Public ❑ Other El Delta Depth of Grout Seal _ Typebf Grout D Irrigation - A� f :� "` ! g --Approx. Depth ❑ Eastern Surface Seal,installed by Repair Work Done ❑ Type of Pump 71- — H.P. .^ "_ _ _ State Work Done ') Well Destruction 0 Well Diameter — l Sealing-Material {top 5011 ' i -4 t 3 Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION)t REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is x.' -' r available within 200 feet.) Installation will serve: Residence Y Commercial—r Other 'r Number of living units: Number of.bedrooms Character of soil to a depth of 3feet: { t Water table depth i SEPTIC TANK , ❑ Type/Mfg' �`r Capacitye2,09 _ NoFCompartments d PKG. TREATMENT PLT. ❑ `► '� j /Method of Disposal Q Distance.to nearest: Well ) Fountlatioh Property Line LEACHING LINE T .❑ No. & Length of lines } ^~ r t Total length/size FILTER BED r� ❑J Distance to neare_st:..'A. Well Fourndatioii Property Line 1� SEEPAGE PITS i Depth �� -� - Size �� Number r 10 , r SUMPS �. � Distance to nearest: Well�� Foundation---�-�- Property Line�•- DISPOSAL PONDS ❑ I hereby certify that.1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulatioris 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-eaeson'in such manner-as to become subject to workman's compensation laves of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in therformance of the work for which this permit`is issued, I shall employ persons subject to workman's compensa- tion laws of California." s % The applicant ust call for all requir pections. Complete drawing on�reverse side. Signed Title: Date: FOR DEPARTMENT--USE_ONLY Application Accepted by W9 Date `Z �1 Area Pit or Grout Inspection by Date Final Inspection by Date D Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 h Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CMH RECEIVED BY DATE PERMIT'ND. + EH 13-24(REV.1/8 s) EH 14.28 C1 e5 a c7 , a a 0 5Q5 Com- - �F�o ��c-?70