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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 (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 8151CCO ASSO/Y SiT�•G• city TYALot Size PM a Hit S'u nst Owner's Name IGIX A is Address LcT -"If/ Phone Contractor " -e S4'-Y Address 400.3 J9LtV 1' 0 /400- License No. 0� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NREST: SEPTTC`T7a1VK`_._. .._.....,__� ...__,SEER t►NES m 5t3P(3Ort FtB 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 Q4favel Pack '.d racy r. ':.'Fype-of-Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by _ C Repair Work Done ❑ Type of Pump H.P. State Work Done_ 0 Well Destruction ❑ Well Diameter Seating Material (top 501 Depth (Below 501 _ TYPE OF SEPTICWORK: NEW INSTALLATION N,, REPAIR/Ap ITION DESTRUCTION I I (No sepjiic system permitted if public sewer is A ----• - available within 200 feet.) 0 Installation will-serve: Residence L Commerciat`_"'other Number of living units: —L Number of bedrooms I (/! Character of soil to a depth of 3 feet: Water table depth �1' t^ SEPTIC TANK ❑ Type/Mfg acity No. Compartments PKG. TREATMENT PLT. ❑ IJ M`thod of Disposal Distance to nearest: Well Foundation Property�l 1 ine LEACHING LINE' ❑ No.&_Length.Df-lines _,____ ___.._ __. _.. , ___.. _ ,__._--_.brarldrrM/size A\ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Shy s►ze 6, la�X 8� _,.Nytmher SUMPS 1C Distance to nearest: Well Foundation Property Line �O DISPOSAL PONDS ❑ ! I hereby certify that I have prepared this application and that the work will be done in accordance with'San Poaquirl county ordinances, state laws, and rules and regulations of the San;Joaquin Local Health Di1trict. Home owner or licensed agent'sysignaturi Certifies the following: "I certify that in the performance of the w(*k 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 thi$permit is issued,1 shall�mpry persons subject to workman's compensa- tion laws of California." i The applicant must 11 for all required.inspections....Cnmplate.drawing on.saver"side.__ Signed X Title: Date: FOR DEPARTMENT USE ONLY ' Application Accepted by Date 3 Area 2`� Pit or Grout Inspection by Date Final Inspection by ate 6 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 206, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. _ ._..._ EH 13 24 �O �j �'9�.�S3Lf _ EH 14-2e 09 �T ,.