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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA " + Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7S—/ 1-4- - Cit Lot Size PM Owner's NamQ_15 J Address w Phone Contract alkress 4 z- �, _'{�License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.O DESTRUCTION ❑ 'PUMP INSTALLATION ❑ SYSTEM REPAIR,❑ OTHER ❑ € DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION.' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ # " INTENDED-USE- ` �TYPE OF'WELL�rtPROBLEM Af3ER�CONST'RUCTION-SP'EGIPtCATi -4....:. - `' ` '7 ❑ Industrial ❑ Open Bottom-—LlMariieca "Dia:of Well_.Excavation -.Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack�r__^ E1=Trecy____ .r Type ofb;59i J Specifications FI Public ❑ Other Win:Delta Depth of Grout Seal Type of Grout---- I I Irrigation -Approx. Depth I I Eastern ,,-1 Suribc Seal Installed by, _ ! Repair Work Done ❑ Type of Pump. H.P. State Work Done Well Destruction ❑ Well Diameter # Sealing Material (top`50') Depth r f'f Filler Material (Below_ 50T- TYPE OF SEPTIC WORK: NEW WSTALLATIO REPAIR/ADDITION I 1 DESTRUCTION I"9 Mo septic system permitted if public sewer is /r available within 200 feet.) J Installation will serve: Residence /� Commercia�__ Iher__ - Number of living units: � Number of doom Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ " "'Method of Disposal Distance to nearest: Well Foundation Property Line _ f f LEACHING LINE / No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well". � Foundation /�/ Property LineQ f l� SEEPAGE PITS Depth Size Number ; SUMPS ❑ Distance to nearest: Well.�A Foundation/_ Property Line_... 7S7,'. } -DISPOSAL PONDS Cl 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, _ rules and regulations of the-San Joiquin Local Health District. - Home owner or licensed agent's signature certifies fhe foflowirig: ''I certify that in'tFie performance of the wofk for which=this permit-is issued;_4shall 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 t call fa al dqLAed inspections. Complete drawing on reverse sid Signed X Title: V Date: 2111 \\el^ 90 0 FOR DEPARTMENT USE ONLY �y Application Accepted by Date 1 C�" / — Area bit r Grout Inspection byr t r inal Inspection by ates Additional Comments:T ❑ 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 95.201 3 -� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH r +.EH13-24(REV.r/H sl EH 14-26 t �`-F