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� YR . APPLICATION FOR `PERMIT" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1 YEAR FROM DATE-ISSUED . (Complete in Triplicate),i 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 L 71 City 'I Lot Size / enrie. PM Owner's Name � `Q ¢iAddress .._7;A44r, Phone i Contractor A Address - License No Phone 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ` t PUMP INSTALLATION ❑ SYSTEM REPAIR f1OTHER ❑ DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N__ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE%A,REA CONSTRUCTION SPECIFICATIONS i ❑ InduMrial ❑ Open Bottom ❑ Manteca '-Dia.,Df Well Excavation .fid (Dia. of Well Casing � ❑ Domestic/Private ❑ Gravel Pack [],,,Tracy Type of Casin. Y Yp g�- .__ �Specifications ❑ Public ❑ Other "'"""^ '—❑'Delia Depth of Grout Sea Type of Grout ❑ Irrigation _�lpprox. Depth ❑ Easter,Surface Seal Instalie'd by E Repair Work Done ❑ Type of Pump �Ii:P: ti `•' State Work Done ti f Well Destruction ❑ Well Diameter Sealing Material [top 501 r,`� 'T DepthFiller Material-(Below 501 1:; I TYPE OF SEPTIC WORK: NEW INSTAL IONS REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public,sewer is if available within 200 feet.) J = Installation will serve: Residence��///� Commercial n Other T s Number of living units: _I— Number of bedrooms 3 q r Character of soil to a depth °f 3 feet: o Gj? ° Water table depth SEPTIC TANK f�7+ Type/Mfg G Capacity_ja7.� No. Compartments f PKG..TREATMENT PLTJ❑ i r Method of Disp9sal 4 r o Distance to nearest: Well--So Foundation� Property Line e) k LEACHING LINE" No. & Length of lines 3 _ T tal length/size FILTER-BED ❑ Distance to nearest: Well f9p o ndation—* 9-_ Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS. ❑ Distance.to nearest: Well• - Foundation Property Line " ! DISPOSAL PONDS ❑ y I hereby certify that 1 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.. f 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 applicant must call for all requi d'in pections. Complete drawing on reverse side. r ' Signed X T'd Title:—A a�n-r Date: 6 3 I I FOR DEPARTMENT USE ONLY L Application Accepted by Date ~ Area 4 Pit or Grout Inspection by Date Final Inspection by 0 Date 11191 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicarit- Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O.Zox 2009, Stk., CA 95201 " INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH'13-241REV.ves) EH 1426 t i