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r APPLICATION..FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in.Triplicate) !j 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 of Size PM Owner's Name Address Phone Contractor A611t FCAZ _ff Address License Phone J : TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other f i...Cl Delta , Depth of Grout Seal Type of Grout i I Irri ation A rox�'De`th'�l I'Easter`n�''; i ,surface Seal Ihstalled b g —_ pp P, k , . y - Repair Work Done ❑ Type fof,Pump _ H.P. State Work Done _ Well Destruction ❑ Well Diameter '' '�' -� Sealidg^Material (top 501 t Depth Filler Material (Below 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) TInstallation will serve: Residence Commercial_ Other, i. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth/ r}E SEPTIC TANK sK{J ❑ Type/Mfg R, 0 Capacity No. Compartments t.i F PKG. TREATMENT PLT. ❑ r{' ' // - Method of Disposal f Distance to nearest: Well Foundation -L - Property;Line LEACHING LIN£%' � No. $ Length of lines r Total length/size Ji FILTER BED Distance to nearest: Well Fo6ndation�d_1j240v'W Property.Line—,P SEEPAGE PITS ! I DepthSizr3 P .�l - ' "„Number s- SUMPS El Distance to nearest: Well._.._'-_..__... !,FounJation ?: Property Line i t DISPOSAL PONDS El ; At +. I hereby certify that I have prepared this.application and the;the.work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health'Disfrrct. 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 workmari's;compensation laws of California."Contractor's hiring or sub-contracting signature s 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- j. tion'laws of California." t`} ;. s e The applicant must cat/ r all re wired in pections. Complete drawinb on reverse side. a OOAO s. . Signed X <OrA Title:- Date: FOR DEPARTMENT USE ONLY Application Accepted by —b__ �1 G--C ! C Date / Area s Pit or Grout Inspection by Date aF Final Inspection by i. i Date O 4 1 Additional Comments' t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 T t Applicant - Return all copies to: Environmental Health Permit/- Baruices 1601E Hazelton Ave., P.O. Box 2009, Stk., CA;95241 ' E ir FEE AMOUNT DUE AMOUNT REMITTED F CK RECEIVED BY DATE PERMIT•NO. k I INFO ' CASH t a.EH 13-21(REV.