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` r � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephone (209) 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) k rmit to construct and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local Health District for a pe 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. t �/ ICity n 1 Z 7� Lot Size ��`�- PM Job Address �7l l f r ' DAV I ID i f 140 HAS AddressAVI V Phone Owner's Name r„ Contractor's Name S'Arl� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT WELL OTHER WELL- INTENDED INTENDED USE TYPE OF WELL R LEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing D Ma ca Dia. of Well Excavation C3 industrial ❑ Open Bottom r��r Specifications ❑ Domestic/Private ❑ Gravel Pack" racy Type of Casing ❑ Public �_O,ther El Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. D h Q Eastern Surface Seal Installed by . r H.P. State Work Done Repair Work Done ❑ Type of Pum Well Destruction ❑ Well Diameter Sealing Material (top 501 (f' Depth I Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW wi INSTALLATION REPAIRIADDITION 12 DESTRUCTION ❑ eNailabpe�within 200 feet.) itted if public sewer is Installation I serve: Res encs X Commercial Other (�w r Number of living units: Number of bedrooms� + -f Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ..t} / gg,�, Method ofppsal * 4 V& Ob Property Line 6 Distance,to nearest: Well lG Foundation P rtl+ } LEACHING LINE No. & Length of lines �yTotal ength/size r - C7+L/ �0 1 FILTER BED ,❑ Distance to nearest: Well l � Foundation Property Line r I SEEPAGE PITS Depth'I Size ber a Property Line SUMPS ❑ Distance to nearest: Well_. �- Foundation DISPOSAL PONDS Ll I I hereby certify that I have prepared t-his 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." Contractors 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 laws of California." v The applica t must call for qui spections. Complete drawing on reverse side. 1Z_ /Z Signed Title: Date: F D TMENT U � �� Application Accepted by Date Area { Pit or Grout inspection by Date Final Inspection by Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 Q Tracy 835 5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I -� FEE CK RECEIVED BY DATE EPERMIT'NOINFOAMOUNT DUE AMOUNT REMITTED CASHS 3.5'7 + EH 13-241REV.101831 = o EH 1426