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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES 4 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 Address16J — le 0 / L M City Lo Int 1 Lot Size A C— PM Owner's Name AI { Address , A r E,0N 10 Phone �' t Contractor[.[Jra _1,00i) Address 1License No. Phone 74 S— TYPE OF WELL/PUMP: NEW WELL^ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ �O��T''H/EER ElDISTANCE TO NEAREST: SEPTIC TANK I S70 SEWER LINES Ste— DISPOSAL FLD.S ,f._. PROP. LINE 3 FOUNDATION LSC) AGRICULTURE WELL =-Ip= OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS cr ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing IDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing rt 4�_ Specifications � " F1 Public fl Other C .l Delta Depth of Grout Seal /60 t Type of Grout � a�.� - I ( irrigation �.Approx. Depth I I Eastern Surface Seal Installed by G�ot�dS 4_J Zrgpq t/� Repair Work Done ❑ Type of Pump H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 SA N d =k- C-,Trill r a� — Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_____ Commercial_ Other Number of living units: Number of bedrooms 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 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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 Di1trict. 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 ust call pfor fall required in ctions. Complete drawing on reverse_sida. _ Signed X Title: �Q/Il II9Ii Cj i QP— Date: /� rA v 47 FOR DEPARTMENT USE ONLY Application Accepted by" Date 9 Area ! 2— Pit o Gro t Inspection by to! — Final Inspection by��1 ///3�r7 Date ' 3 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 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT NO. INFO +.EH 13-241REV.1/855 —>-fl EH 14-26 2 a�--