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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 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. e Job Address City Lot Size CftE� PM if i �l Owner's'Name. � �,�•! ►�.Elm)CF-t�Address < At.60 ni& p—e- 6 Phone c Address_f � 7 f 1 rt �C �c License.No.Zq es� Phone f 7? Contractor - TYPE_OF._W.ELLIP_UMP_:., ,,. .,,,,,. NEW ,WELL,REPLSQEMENT 0�.DESTRUCTION ❑ t PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0- DISTANCE TO NEAREST:'SEPTIC TANK I bo �..__ SEWER LINES DISPOSAL FLD. _I PROP_LINE FOUNDATION 3 D __ AGRICULTURE WELL S OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ` ElIndustrial ,KOpen Bottom ❑ Manteca Dia. of Well Excavation A=ik x Dia. of Well Casing KDomestic/Private ❑ Gravel Pack 0 Tracy Type of Casing g� S�PGI Specifications R ❑ Public ❑ Other ? ❑ Delta" ",,,,,Depth oaf Groout,'Seall 92 Type of Grout_ I I Irrigation c`3-� Approx.depth 11'-Ea�et�ern Surface Sea] Installed by t/e��p u �R�f+�A a - Repair Work Done ❑ Type of Pump � omE H State Work Done ~ Weil Destruction ❑ Well Diameter � - Sealing Material (top 50;1 Depth Filler Material 18elow 501 y TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR!.ADDITION-6-I.-DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ -Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f _ Water table depth ' SEPTIC TANK ❑ Type/Mfg! Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I I Distance to nearest: Well Foundation Property Line 1• n LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line } - SEEPAGE PITS I I Depth Size Number SUMPS LlDistance to nearest: Well Foundation 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 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: t'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 laws of California." s The applicant mu call for all required inspections. Complete drawing on reverse side. e Signed X Title: ec Date: t FOR DEPARTMENT USE ONLY 4q,� -. o Application Accepted by / Date Area Pit or Grout Inspection by Date r Final Inspection by Date Z5W Additional Comments: ❑ 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 � FEE INFO AM/O +�UNT DUE'� - AMOUNT REMiTrED CA5l1 y J�RECEIVED BY DATE PEE//RMIT'NO. + EH 13-24(REV.15) - EH 1429 V !!!