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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address L 3 L M ac l{l m a_ QA• City of size I A LRE S_ PM j Owner's Name A/Au 6y/ .-."Od Address602 9 , A Ji° CtilF � Phone -f 7 Contractor S� � Address f ' License No. Phone F _ TYPE OF WELL/PUMP: NEW WELL ❑,� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP..IINE FOUNDATION AGRICULTURE WELL _ OTHER WELL - PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation � Dia. of Well Casing l 11Domestic/Private ❑ GravelPack ❑ Tracy. Type of Casing Specifications ❑ Public ❑ Other i 71pelta Depth of Grout Seal Type of Grout ❑ Irrigation 7--Approx. Depth ❑ Eastern Surface Seal Installed by: Repair Work Done El of Pump H.P, State Work Done Well Destruction ❑ Well Diameter -Sealing"Material (top 50') a Depth :Filler Malarial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is N1available within 200 feet.) Installation will serve: Residence 1! Commercial_ Other Number of living units: Number of bedrooms t.._ Character of soil to a depth of 3 feet: 4 Water table depth F SEPTIC TANK ElType/Mfg d k. Capacity !. No. Compartments PKG. TREATMENT PLT. ❑ If I I Method of Disposal " Distance to nearest: Welt aCp.�Foundation .S0 Property Line l LEACHING LINE ❑ No. & Length of lines z notal length/size n FILTER BED ❑ Distance to nearest: Well nit." Foudation + 1� Property Line '"• SEEPAGE PITS ❑ Depth Lt S� Size zf Number f s SUMPS ❑ Distance to nearest: 1Nellg9MFouri�ation 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 n the performance of the work for which this permit is issued, I shall not employ any person in such rr anner 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 must call for all required inspections. Complete drawing on reverse side. r , l Signed 3 9 Title:��/✓�' Date: _ FOR ARTMENT USE ONLY Application Accepted by Date - Area IO Pit or Grout Inspection by ate_- Final Inspection by pate Additional Comments: �afp� o ❑ 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 (y'� INFO HFEE UNT DUE AMOUNT REMITTED. CASH RECEIVED BY DATE PERMIYNO, " + EH 13-241REY.1/8 51 EH 1of /1/1 428 V L J V(f WW rJ 00 l�