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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES TYEAR 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 , fir+ C. C r 1 E//' City 4YXLot Size PM Ali 1A (� T —� - Owner's Name Address Phone Contractor Address {T. (4 License No37 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,_-,,,DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR--gOTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI014. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WALL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing R- IDJmestic/Privaie ClGravel Pack ❑ Tracy Type of Casing Specifications ',l-1 Public C1 Other Cl Delta Depth of Grout Sea! Type of Grout _ - x 1.1 Irrigation i, t Approx, Dep I Eastern SInstalled by Repair Work Done +lam Typ6 of Pump H.P. u c 5e'I State Work ne Well Destruction ❑ Well Diameter Sealing Material h p 50'1 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if publj�y available within 200 feet.) ��//JJ1��fj1(��/''■lJ►(/�J Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms a 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 k _v s Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total Length/size \( FILTER BED 0 Distance to nearest: Well Foundation Property Line t SEEPAGE PITS l I Depth Size - r 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 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;l shatt 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 certif in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif rnia." The.applica ca f r. 1q. re rn cions:- plate-drawing o re side. Signed X "^^" a _ Title: Date: - - - _ 1 �_ + _ - FOR PEPARTMENT USE ONLY; Application Accepted by 1 Date ` Area 6 a Pit or Grout Inspection by Date Final Inspection by Date A itional Comments: fX'Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 �Oplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . + EH 43-24IREV.i/nsf � '�^ EH 14-2e