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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TY>EAR FROM DATE ISSUED p (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 f Local Health District. Job Address _ � G✓, /yl/CIFD ' /� ...._ City R Lot Size t,ff1` �� PM Owner's Name KkbJ24 Ore i Aft eli_ Address Phone Contractor azi. keW Address #ZM IV,9!: spi License No. Phone_ 91093 TYPE OF WELL/PUMP: NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ --PUMP-INSTALLATION-4-1. -•-- SYSTEM REPAIR-❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK} SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION"-- AGRICULTURE.WELL,-- OTHER WELL PITS/SUMPS1<31 INTENDED USE TYPE OF WE 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑:Gravel Pack1, ❑ Tracy Type of Casing Specifications 1`1 Publict .. ❑ Other DoT Cl Delta Depth of Grout Seal Type of Grout I I Irrigation, `...Approx. Depth i I Eastern Surface Seal Installed by [� Repair Work Done LJ Type of Pump,I H.P. State Work Done Well Destruction i]°'Well Diameter Sealing Material ftop 501 Depth r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION H REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is 3 available within 200 feet.) Installation will serve: Residence Commercial_ Other F Number of living units: Number of!bedrooms')'.- Character of soil to a depth of 3 feet: rlI Water table depth SEPT c_ ❑ Type/Mfg r Capacity No. Compartments Uv PKG. TREATMENT PLT. ❑ Method cif Disposal f -� Distance to nearest:," -Well, __.�_._ Foundation Property Line LEACHING LINE ❑1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ` Foundation Property Line I I SEEPAGE PITS I I Depth I Size Number SUMPS CI Distance 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: "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 applicanimvst call f all required i 'pec' ns. Complete drawing on reverse side. f _ 1 Signed X Title: Date: R'DEPARTMENT USE ONLY q r+ Application Accepted by " Date 4 Area t Pit or Grout Inspection by i Date Final Inspection by Ta"k ��"'`"'�°r Da Y Additional Comments: k QS Cv7tr�e�5a ❑ Stk 466-6781 Lodi 369-3621 ► '❑ Manteca 823-7104 ❑ Tracy 835-6M5 w Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BZ 2009, Stk., CA 901 11E UNT DUE AMOUNT REMITTED CK L-?j CASH RECEIVED BY DATE /PEERiMIT NO.. ♦.EH t3-241REV.t/x5S C;� .s/tO �7/ 00 EH 14-29 c•Ve l! v V --s I / G� ! !! OC(IIP I