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I APPLICATION FOR PERMIT i� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA ' Telephone (209) 466-6781 t PERMIT EXPIRES 1-YEAR;FROM DATE ISSUED �. ij (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 l Ll C - e L M City Lot size PM + - - r - - —_� (j Address �3 I Phone Owner's Name; o Contractor's Name Kos License No. 3 �i � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .'i; d i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑' OTHER ❑ .DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES — DISPOSAL FLD. PROP. LINE J- ;i FOUNDATION AGRICULTURE WELL __ OTHER WELL_ PITS/SUMPS r ` INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications L ❑ Public iq ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1Q7 ❑ Irrigation �! ---Approx. Depth ❑ Eastern Surface Seal Installed by- El State Work Done Repair Work Done•.z,❑ Type of Pump .. Well Destruction ElWell Diameter Sealing Material (top 501 Depth fL.� Filler Material (Below 501 Isewer TYPE OF SEPTIC WORK: NEW INSTALLATION I9 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitte fi available within 200 feet.) d r` Installation will serve: Residence— Commercial_, Other, h o� Number of living units: d Number of bedrooms 6 Character of sot!to a depth of 3-feet: ^'p. L Water table depth SEPTIC TANK �❑ Type/Mfgi_. Prc�rt S CapacityJAA_� No. Compartments PK& TREATMENT PLT. ❑ Method of Diisspgsal �I Distance to nearest: Well l 5^0 Foundation Property Line d LEACHING LINE No. 8a Length of lines Total len th/size 9� ' FILTER SED �� 1:1 Distanceto riearest: Well Foundation Property e SEEPAGE PITS ❑ DepthS e 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 applicant ` ust call for ilk.required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area 1 Pi or Grout Inspection by r Date 2- 'tion "Final'Inspection by L Date�.�-Lr ;Additional Comments: �s. • ❑T Stk 4V,681' ❑ 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 �- I IN E AMOUNT DUE AMOUN REMITTED CASH RECEIVED BY DATE PERMIT"NO. EH 1324(REV.401 I.d t aEH 1428 .