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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 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /0,- 30 0, 30 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 4 ']� r� � City - Lot Size PM Owner's Name { BIZ- �'":F Address T"'cx moe Phone r Alch&ros po 7,76 A65120W Le 3l Contractor Address �License No. Phone TYPE OF WELL/PUMP W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ m DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA ''CONSTRUCTIDN SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ R Specifications f7 Public CI Other n Delta Depth of Grout Seat` Type of Grout I I Irrigation _.Aoprox. Depth I I Eastern Surface Seal Installed by ' t� Repair Work Done CJ Type of Pump -. H.P. State Work Done_ f Well Destruct'n ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I 1 IND 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: --Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal " Distance to nearest: Well Foundation Property Line LEACHING LINE IN No. & Length of lines Total length/size 4aI 1b� FILTER BED ❑ Distance to nearest: Well ILE:)f—' Foundation Z b Property Line i SEEPAGE PITS y yN Depth ;D, r Is Ize f 1) 1,-, Number SUMPS 0 Distance to nearest: Well Foundation ) Property Line —�b i 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 rifles 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 shalt 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 applicant st call for all re ms ions. Complete drawing on reverse side. Signe Ti1le � 1 Date: r O EPARTMENT USE ONLY v-`3 Application Accepted by - Date .Area �p , Pit or Grout Inspection by Date J /� Final Inspection by F Date 4 Additional Comments: . �' Leo. r- L_[ —Q iA (/ ❑ Stk 4&6 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy BA686 12 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUEJ� Vv AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO : �} CASH r.EH 13-24 1REV.11 H sl EH 14-28