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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 Co my Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 3 6 co U �C 4 Jf 0 6, f4f- Job Address 4! /1 .1 3 J 'S C City ACLot Size �3 ®� PM Owner's Name Czt�A + Address Phone �e E3&_g3`(C ✓��. Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO N T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W DATION AGRICULTURE WELL OTHER WELL PIT U INTENDED USE TYPE OF PROBLEM AREA CONSTRUCTION SPECIFIC C ❑ Industrial ❑ Open Bottom anteca Dia. of Wel ion Dia. of Well Casing rJ El Domestic/Private El Gravel Pack El Tracy a of Casing Specifications a F] Public ❑ Other of Grout Seal Type of Grout ._- I I Irrigation _ A epth I I Eastern Surface stalled by Repair Work Done ype of Pump H.P. tate Work Done_ �- G Well Destruction ❑ Well Diameter Sealing Material (top 501 j epth Filler Material (Below 501 -_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is avable within 200 feet.) Installation will serve: Residence-)(- Commercial_ Other--��i C �` eA4C P l 0t0 4e S. 1 Number of living units: Number of�btedrdoms N Character of soil to a depth of 3 feet: C,4 Water table depth W SEPTIC TANK ❑ Type/Mfg I/,QA C—CPk itA Capacity-JA-40-262-0— No. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal S Distance to nearest: Well ° �� Foundation 10 Property Line LEACHING LINE No. & Length of lines �� s Total length/size O K FILTER BED ❑ Distance to nearest: Well Foundation f Property Line Ito SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line 146 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 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 calZ22 d inspections. Complete drawing on reverse side. p Signed X + t Title: v �1 / �i� Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date � ( �'� Area L Pit or Grout Inspection by Date Final Inspection by Date 3 3o O Additional Comments: L' Ur^ i 04 '� ,2 o , l✓u cr 3 27 40 ❑ 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 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO + EH13-24 IREV.i/e 5) EH 14-28 Q�C5O