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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTI ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �Q i 7 1 o uc_� (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 U�� City J"ll'©�� Lot Size 1 !!QV AcY-W—(.(P�M2 � Owner's Name ryes AddressD rS Phone2D � "`�`� `�� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE TRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS E) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private rave ❑ Tra Type of Casing Specifications f"l Public ❑ Other Depth of Grout Seal Type of Grout I I Irrigation _Approx. pth l I Eastern - 6 Repair Work Done ❑ Type o mp H.P. State Work Done Well Destruction ❑ W Diameter Sealing Material (top 501 epth Filler Material (Below 50'1— TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRYADDITION 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 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg "Capacity ZUV No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 7-00 Foundation r_0 __- Pfoperty Line 17-V " LEACHING LINE —No. & Length of lines C Total length/size "L FILTER BED ❑ Distance to nearest: Well Foundation tJr Property Line SEEPAGE PITS I I Depth Z Size T1 — �,N-umber SUMPS Ll Distance to nearest: Well Foundation s� Property Line `LU DISPOSAL PONDS D I 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 " T 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 Caiifor ia." n' The applicant ally all fired n pections Complete drawing o/nve4rs/e�side. Gr• v a7'✓ !V , Date: /�+ I A" Signed Title: _- - FOR DEPARTMENT USE ONLY Date 7— Area A plication Accepted by Pit r Grout Inspection1;7 atZ /J D Final Inspection by� 'f �' Date Q Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE- AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO . EH 13-24IREV,I/n5) ""IT EH 14-26 1