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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. (� c { � f Job Address � 1� `� a` ` "'�� City &4Lot Size PM Owner's Name Address _ _ _ _ Phone e' `a � Contractor(9 "S E""- %C—Address0"8CX3 ON-,ALI& sT license No.y9o0 e Phon TYPE OF WELL/PUMP: NEW WELL EJ 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 INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS < ❑ Industrial ❑ Open Bottom ❑ Manteca ''Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El-Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Depth ❑ Eastern 'Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 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.) Installation will serve: Residence CommerciaiOttley Number of living units: J0 Number of bedrooms 1 Character of soil to a depth of 3 feet: &1!4A_3 qZWater table depth SEPTIC TANK Type IMfg R�tCapacity/660No. Compartments {� PKG. TREATMENT PLT. ❑ 1 + Method�f`DisplosaI Distance to nearest: Well 10+ Foundation ;20 Property Line ;7Qp LEACHING LINENo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel14W7C , Foundation. Property Line 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,1 shall employ persons subject to workman's compensa- tion fawn Ca i nia." _ « v The apple an must all for uved inspections. Complete drawing on reverse side. S Signed A Title: �{�_ Date: `r v FOR DEPARTMENT USE ONLY �{ Application Accepted byCb XS r 'Date •~ 78b �Area Pit or Grout Inspection Date Final Inspia6n by '�� 5`pp. %f Dat 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83548385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY Q DATE PERMIT"NO. +EH 13-24IREV.lie 5) EH 14-28 rs