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APPLICATION FOR PERMIT � . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 ND PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) OL) .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 [ C? /!o City"E�O 'l 0) Lot Size PM Owner's Name 7T�G Address -.l--"n!-_2& L(J fN 0Lsd R, Phone 63'TYContractor A1. ddressil6g �6 a"4 p� License No. Phone2461.3— TYPE PE OF WEL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . a FOUNDATION AGRICULTURE WELL. OTHER PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREACONSTR SPECIFICATIONS r-+ ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing ❑ Domestic"'""to ❑ Gravel Pack ❑ T Type of Casing Specifications F1 Public C1 Other f 1 Delta ;. Depth of Grout Seal Type of Grout I I Irrigation A rox. Depth I I Eastern Surface Seal Installed by r - Repair Work Done ype of Pump ^�H-P:�� State Work Done Well Des on ❑ Well Diameter Sealing Material (top 50'1 E Depth- Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION i.I DESTRUCTION l No septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence= Commercial= Other a Number of living units: Number-of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r 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 SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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." The applicant m41st call for all require spections. Complete drawing on reverse side. Signed X Y� Title: r r� Date: kA,aAZ iF DEPARTMENT USE ONLYApplication Accepted by ��ou.,, k , � arh Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments• l�o ❑ Silk 466-6781 E3odi 369�621 L ❑ Mle., 823-7104 ❑ Tracy 835 6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. ♦ EH 13-26(REV.r/H 51 G 3� t3 a EH tdda 7 1J► t� J �j