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4 APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON 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/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 __ � � / _ City Lot Size PM / � fj E Owner's Name�L1_�rpj_ �14% �e.3 C, Address gC� Phone Tto� Contractor Address License No. Phone ,CCC TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ❑ DESTRUCTION El INSTALLATION 11 SYSTE EPAIR CJ OTHER ❑ DISTANCCTO NEAREST: SEPTIC K -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT WELL OTHER'WELL PITS/SUMPS _ INTENDED USE TYPE OF WELLOBLEM A A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJ a Dia. of Well Excavation Dia. of Well Casing 4 _- El Domestic/Private ❑ Gravel Pack ❑ acy Type of Casing Specifications " M-Public I-1 Other Delta Depth of Grout Seal Type of Grout _ 'I I Irrigation --.Approx.. th I I Easternurface Seal-lnstalted by--- Repair y-- Repair Work Done ❑ Type of P p k H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material top 50'} Depth --'"' Filler-Material-(Below-50')-— s—— TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I } INo septic system permitted if public sewer is available within 200 feet.) n_s�mber of living tallation will serve: Residence v Commercial Other q Nuunits: +±"�-`-i-Number of bedroo s 3 r Characte f-soil to a depth of 3 feet: i Water table dept h _SEPTIC TANK I! EJType/.Mfg, -P�(t�, s,�� Capacity 1-7 00 No. Compartments ,PKG-_TREATMENT'PLT. ❑ ;C.. Method of Disposal .� I r. ` W.Distance to nearest:t Well Fpundation � _ Property Line a 'LEACHING LINE ❑' No.`& Length of lines O Total length/size i FILTER BED ❑ Distance to nearestde Well b0 '' Foundation V6 Property Line:760 ` SEEPAGE PITS I I Depth Size Number I i t SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' hereby certify that I have prepared this application and that the work will be done in accordance with San count Joaquin rules and regulations of the San Joaquin Local Health Diltrict. q y ordinances, state laws, ori 0 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 notD employ any person in such manner as to become subiect 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 required inspect!qns, Complete drawing on raver side. Signed X itle: Date: i F. DEPARTMENT USE ONLY Application Accepted by Date B Area Pit or Grout Inspection-by —Date- - -- -Final-inspection-by, Date Additional Comments: CW �t/ 17) S4k 466-6781 ❑•Lodi X369-3621 ❑ Manteca. 823-7104 ❑ Tracy 635 5 /1 f .Applicant- Return:all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave', P.O. Box 2009, Stk., CA 95201 FEE 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EHt3-241REV.riHs1 C)_ 7 ' �o. EH 14-IB x