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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE.; STOCKTON, CA Telephone (209)A66-6781,- PERMIT 209).466-6781PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED i a r (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 q 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. rl x Job Address �' "' �`d` Cr �: City Lot Size PM 72 Owner's Name * L''z� Address T Phone Contractor z1-l- s1a Address �� r License No. Y Phone TYPE OF WELL/PUMP: I� NEW WELL 171 WELL REPLACEMENT DESTRUCTION ❑ ~� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. OP. LINE FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE 1�TYPE OF WELL PROBLEM AREA CONSTRUCT CIFICATIONS ❑ Industrial Il Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public 0 Other Delta Depth of Grout Seal Type of Grout ❑ Irrigation IM x. Depth O Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Done F ell tion ❑ Well Diameter Sealing Material (top 50'1 Dfepth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: KNEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence— Commercial Other Number of living units: 11 Number of bedrooms Character of soil to a depih of 3 feet: Water table depth SEPTIC,TANK ❑;� Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line. LEACHING LINE ❑, No. & Length of lines Total length/size FILTER BED ©` Distance to nearest: Well Foundation Property Line I SEEPAGE PITS C7 Depth Size Number SUMPS ❑` Distance to nearest: Well Foundation - Property Line 0 DISPOSAL PONDS ❑. 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."Contractors 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." 1 The applicant must call for all required inspections. Complete drawing on reverse side.. k15r `l� s r c Signed Xs�-.f ' !/l� ... . ` Title: Date. �. pOR'DEPARTMENT USE ONLY Application Accepted by F '''Date Area Pit or Groutg Inspection byl� Date// Final Inspection by ate Additional Comments: r ❑ Stk 466-8781 ❑!Lodi 369-3621 ❑ Manteca 823-7104 El Tracy Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J� FEE AAAOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO + EH 13-24 IREV.I/8 5) EH 14-28