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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ow-cr--l-d .)V- -44 (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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. (_ a OI].—1,? ��✓y pitv Lot Size PM Job Address Owner's Name Mess Phone Contractor R1 I I tyAddress a tato. Phone TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL LA I ❑ S REPAIJHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK EWER LINE SPOSAL FL PROP. LINE FOUNDATION AGRICULTURE THER WEL PITS/SUMPS ./ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT N 16 ❑ Industrial pen Bottom [I Manteca Dia. of Well Excavatio Dia. of Well Casing Com /Private 1-1GravelPack 0 Tracy Type of Casing Specifications 7 ./ i _ f ,blic P Other ❑ Delta Depth of Grout Seal I Type of Grout I 1 Irrigation Approx. Dept I E terfl Surface Seal installed by Repair Work Done LJType of Pump State Work Donezft �- Well Destruction El Well Diameter �� ealing Material (top 501 A Depth Filer Material (Below 50'I f E_ ._ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence_ Commercial_ Other r-' Number of living units: Number of bedrooms_ 4 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Totat length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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, I shall notes employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature k certifies the following:"I certify that in the p. ormance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of Californ' .' The applicant i s c for all r uired i tions. omplete drawing on rever ide. Signed X Date: /7 ARTIVIENT USE ONLY Application Accepted by Date _t6fR L Area Pit or'Gr t Inspection by Date — Final Inspection by �DatezLl,� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 1. FEE LL AMOUNT �DUE AMOUNT REMITTED CASH CK 41 RECEIVED BY DATE PERMIT'NO. . EH13-241REV.riNsu EH 14-29 i0{�r b��Q � RI^ r ` 11 l/ 1J 1 —?.t,�