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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZE t ON AVE., STOCKTON, CA Telephone (209) 466-6781 r 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 4 Ith District. 1 Job Address A=� f f p C_ G[�(�t _ city tD, o Lot Size PM Owner's Name 0(J/ —4. it' kI Address ��r 1'�awle Phone LCon ,actor�b.1 e+�o � Address r� I '11U r'License No. 4 �� 7 Phone�� TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISP D. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ OpenBottom ❑ Man Dia. of Well Excavation: Dia- of Well Casing ❑ Domestic/Private El Gravel Pack racy Type of Casing Specifications f'l Public 171Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation App . Depth 11 Eastern Surface Seal Installed by _ Repair Work Done FIType Pump H.P. State Work Done_ Well Destruction 1-1W II Diameter Sealing Material'Itop 501 Depth Filler Material IBelow 50') or TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITIO DESTRUCTION €:I (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence 2< Commercial_ Other Number of living units: Number of bedrooms �atgr-iablb r Character of soil to a depth of 3 feet: depth �J_Cj. SEPTIC TANK ❑ Type/Mfg Cchs.&� 4704�11V`5 Capacity L04` 4 No. Compartments PKG. TREATMENT PLT. ❑ ice• 1 Method of Disposal Distance to nearest: Well Foundation *' Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑l Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Li Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 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 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 call for all required inspections. Complete drawing on reverse side. Signed X..- �� X,,. �Q _ �r- � Title: /-e �� "6e�n r _ Date: iiAfNT_IfSE ONLY Application Accepted by At ` Date Area WAA PF Pit or Grout Inspection by Date nal Irmpec' n by Date9k�`. 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. Box 2008, Stk., CA 95201 1 € FEE INFO AMOUNT DUE MOUNT REMITTED RECEIVED BY DATE PERMIT'NO. } rEH13-2401Ev.I/Hsy �12 /� 100 - EH 14-26 4J 11