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r"N APPLICATION FOR PERMIT 3 r S- r>- SAN JOAQUIN LOCAL HEALTH DISTRICT `U / 1601 E. HAZE.T 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. I6 6 e PM Job Address A.- �� G Cits 3 y � J /"� Lot SizeAP Owner's Name %i i .� / Z AtZI /q Address ME Phone Af'ZO Contractor's Name 'd9 : �Cicense No. s:q Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial CJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑,�firacy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern---Surface-SeaMnstalled by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 501 01) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION . DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial_ Other Number of living units: 4?__ Number of bedrooms -3 # Character of soil to a depth of 3 feet: 1� 14 A4 Water table depth f 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 SEEPAGE PITS _ Depth _, Size Number SUMPS ❑ iDistange to nearest: Well Foundation_ x Property Line DISPOSAL PONDS Cl 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 taws 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." i T —-.. — The applican call for all required inspections. Co pl to drawing on reverse ide j Signed X Title: — Date: 7 FOR DEPAR�PfiENT USE ONLY 0 Application Accepted by Data Y Area 11 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 6 Z t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant.- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE P INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"N0. + EH1324 tREV.101831 ��g J� ^�c b EH 1428 �{ �4