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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L A i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 Owner's Name ^�wtiG� d^�Yii�(+c�G� Address Phone + tf y�/' G " Contractor Address License NO! 7 I Phone a2---01/1 TYPE OF WELL/ MP: NEW WELL ❑ WELL R PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s ❑ Domestic/Private ❑ Grave! Pack, ❑ Tracy of Casing Specifications f FI Public n Other ❑ Delta asDepth of Grout Seal Type of Grout s I I Irrigation r --Approx. Depth l I Eastern. Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.R. State Work Done Well Destruction ❑ Well Diameter Sewing Material stop 501 Q Depth'— Fi 'flllaterral"(Below 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTIONo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residency Commercial__-_ Other . Number of living units: _�_)j) Number of bedrooms { Character of soil to a depth of i3 feet! Water table depth SEPTIC TANK {y� Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. b } Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No4 Length-of-lines -- Total-length FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS I I Depth 1 Size Number r 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."Contra_ctor=s hiring or sub-contracting signature certifies the following: "I certify that in the performance of f the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic4nl must call for all required inspections. Complete drawir3g-on reverse side Signed X Title: r'`"�U Date: FOR DEPARTMENT USE'ONLY r I s a Application Accepted by � .�*y- �f)am Area 3 Pit or Grout Inspectio Date 7 Final Inspection by = Date�� Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13 Tracy 835-6385 °! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 e INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. + EH13-21 fREV.iiKsy ,•,� � � { EH 11-2a 1