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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON 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 OofGd` 00 City Wam `G ` 014 Lot Size r PM Owner's Name Address 5411 f9-U4 O h �i� Phone e r E a Contractor's Name dT bhp S No:+r Phone TYPE OF WELL/PUMP: NEIN WELL._❑ ;. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,0- SYSTEM REPAIR,❑ , "-. OTHER ❑ DISTANCE TO NEAREST SEPTIC TANKr SEWER LINES _ r DISPOSAL FLD. PROP. LINE 41 t ' . FOUNDATION, . AGRICULTURE WELL' OTHER WELL L PITS/SUMPS c� INTENDED USE TYPE-0 -1VELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial ❑ Open Bottom: ❑ Manteca. Dia...of„Well-ExcavationIt JDia. of Well Casing L1 Domestic/ 13Gra el Pack C1 Tracy Type of Casing Specifications El Public i 130th r ❑_Delta Depth of Grout Seal AType of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done CIpe of Pump H.P. State Work Done + � Well Destruction ,.� ❑ "'Well Diameier Seating Material Itop 50') d !Depth Filler Material {Below 501 TYPE OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is vailable-within 200 feet.). , a Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms IV64en Character of soil 4o a depth of 3 feet: A-a 0-of• Water table depth € SEPTIC TANK �. ❑ Type/Mfg U E t' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dis osal Distance to nearest: Well' Foundation Property Line { LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 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 appli n must call for all requirgd inspections. Complete drawing on reverse side. �7 2 Signed Title: M4,#11 Date: moo` J FOR DEPARTMENT USE ONLY Application Accepted by �v Date Area Pit or Grout Inspection by to 6 �f Final Inspection by ate C7 Additional Comments: ❑ Stk 466-6781 0 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. +EH,1324(REV.10!63) EH 1424