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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 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. Job Address ___.s � •"?� ) kKoulni 5--F, LL) City 7 " Lot Size PM Owner's Name Address Phone p Contractor ��Y'Ct 7�Y�tali Address �• V License No. Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT•❑ DESTRUCTION ❑ DUMP INSTALLATION CJ 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 ❑ Tracyt I Type of Casing_ Specifications Il Public n Other FI Delta Depth of Grout Seal Type of Grout I i Irrigation -Approx. Depth i I Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ LU Destruction ❑ Well Diameter Sealing Material Itop 50'1 v 1 Depth ' Filler-Material-(.Be:low 50 TYPE OF SEPTIC WORK: NEW INSTALLATION is REPAIR/ADDITION i CTION i I (No septic system permitted if public sewer is p„ te' iavailable within 200 feet.) t!� Installation will serve: .Residence '�mmercial Other y Number of living units: __L Number of bedroom. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1�e/Mfg _Ppjacity___/_rM0__0 No. Compartments PKG. TREATMENT PLT. ❑ Method of Dis saI Distance to nearest: W Foundati n Property Line LEACHING LINE Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line E70 J SEEPAGE PITS I I Depth Sizember SUMPS _stance to nearest: Well Foundation 5 Property Line DISPOSAL PONDS ❑ 0�'� F� I 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 Di'strict�- *-» 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 I lifornia." The applicant m s 11 for all quir ins -d;a.'Ing on r rse si Signed TiNe: _ Date: / ti-' g&qA ENT USE ONLY S::L Appllk ication Accepted by —~Date ' T Area `� ' Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 i 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 CK 4 RECEIVED BY DATE PERMIT'NO. INFO CASH a.EH 1324 1REV.)/x 51cQ EH 11-2e 5