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r APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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/of 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 -- ` City Lot Size + `�'Z K;04 APM Ad Owner's NameAddress 150 k+D Phone I Contract rt; a L -.�-Address 103 vim' License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST1-SETIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN FOUND AGRICULTURE WELL OTHER WEL ITSISUMPS f, INTENDED USE TYPE OF WELL OBLEM AREA CONSTRU ECIFIGATIONS ❑ Industrial ❑ Open Bottom.._„ ❑ Man ia. of Well Excavation •Dia—of-Well-Casing—"-'— ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications f'I Public Ll Othe Ll Delta De f Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I I Eastern Surface Sea called by Repair- one ❑ Type of Pump H.P. tate Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION}/I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.I installation will serve: Residence— Commercial Other , Number of living units: Number of bedrooms - �, A Character of soil to a depth of 3 feet: G!� rj� Water table depth j SEPTIC TANK _,e`Type/Mfg. f��+^ G+� Gapacityc3 No. Compartments PKG. TREATMENT PLT. ❑ t ,,Method of Disposal Q . Distance to nearest: Well Foundation 3 a Property Line 1� ' LEACHING UNE o. & Length_of lines ten Total length/size .i FILTER BED ❑ Distance to nearest: Well Foundation b� Property,Line SEEPAGE PITS —1-r Depth �XSSize ,-i f Number �- SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 corrlpensa- tion laws of California." The applicant mu c for all requir inspection omplate drawing on re se srd Signed X2 Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date — Area 1 On r Grout Inspectio Date �% Final Inspection by Date Additional Comments: S -3 ❑ 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 AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT NO. INFO r EH 13-24(REV.t/H 51 uc- EH 14-26 1