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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / I 1601 E. HAZE T ON 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address<>21,3 /'��} ii -- City �LfdLoQsirze PM X Owner's Name � ArtkT�' I Address �� I�1� Ph6ne ?v "g-J - k Contractor's Name • License No. ! Phone TYPE OF WELL/PUMP: VNEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,CZQ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing__ �I�� _ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of ut ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �E Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available.within 200-feet.) – ;"-Installatibri will serve: ' Residence— Commercial_ Other X11 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 G FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Cali rnia." The appli��c r all re it napections. omplete drawing o verse 'de. Signed Title: x� 'Y Date:• d � FOR DEPARTMENT E ONLY ` a Application Accepted by Date O—Z` Area' v i Pit out spection by Ift 3A cl�k Final Inspection by_9"t._S�l..4,y,..C, Date Additional Comments: - ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �? n 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 RECEIVED BY DATE PERMIT"NO..� INFO + EH 13-24(REV.101931 1h4 7 ��Zk 1/ sS 9 EH 14-29 L;> {