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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE. 1 I 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. /l_ Job Address �2 2 r 41<rtl City ��`"� Lot Size PM Owner's Name E �I C Address s /T Phone Contractor_ L f% Address License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Pl S/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ICATIONa - Industrial O Open Bottom O Manteca o Well Excavation Dia. of Well Casing {1 Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications L1 Public f-1 Other f-I Delta Depth of Grout Seal _ Type of Grout__ 1 I Irrigation ox. Depth l I Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Done _ Well Destruc' O Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is N Installation will serve: Residence_ Commercial_ Other -available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth 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 Ll No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 Diltrict. 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 app' ant pv6st call k5arequired inspections. Complete drawing on reverse side. Signe Title: Date: FOR DEPARTMENT DEPARTMENT USE ONLY j r Application Accepted by �Zl Date Area Pit or Grout Inspection by _ �7/ bate 0141 Inspection by - Da Z Z— Additional Comments: r,111 /C�—1042 /Ifo p ' f.JD ❑ Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /4/,11y2 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PER M17'NO. 50 01,voe - I i sENU21IREV,�ixS� 1—� 7 r-' /�,,q��f �y pG Ex 14.2e J J (.��tU�( �'"�� 1 0 7'�115 * 3