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!� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON-AVE., STOCKTON, CA Telephone (209) 466-6781 4 ! PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED i9 (Complete in,Triplicate)P1 r :,. .. Application is hereby made to thef 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 Add10 ress �� City Lot Size / PM ITA7uOwner's Name 'J I^ ^Address �`ry S +— + Phone Contractor L I� —Address, 3 License No. Phone TYPE WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - .,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA T: SEPTIC TANK SEWER LNES DISPOSAL—FLD PROP. LINE A NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —V' INTENDED USE TYPE O LL PROBLEM AREA CONSiALICTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dias, bf Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack = Type of Casing Specifications ❑ Public ❑ Ot4er Delta Depth.of Grout Seal Type of Grout ❑ Irrigation 4ppr epth ❑ Eastern rface Seal Installed-by- Repair Work Done ❑ Ty f Pump H,P. State Work Done Well Destruction ❑ y ,•,ell,Riameter Sealing Material Itop 501 Depth" Filler Material (Below 501), TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ D.ESTRUCTION INo septic system permitted if public sewer is \�\ aNailable within 200 feet.) Installationw ill rve: Residence_ Commercial_ Other Number of living u ' If Number of bedrooms Character of soil to a dep f i3 feet: 1 Water table depth SEPTIC TANK ❑ Type Capacity No. Compartments PKG. TREATMENT PLT. ❑ !� Method of Disposal Distance to nearest: ell Foundation Property Line ail i LEACHING LINE ❑ N` & Length of lines S Total length/size FILTER BED ❑ Distance to near t:. Well Foundation Property Line SEEPAGE PITS ❑ Dept Size Number SUMPS ❑ i tante 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 Joaq aunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health'bistrict. 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 applica st call for all require in ctions. Complete drawing on reverse side. -� /a'7 kP _�7, -�- Signed �!� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted Date .Area Pit or Grout Inspecti a`� Date Final Inspection by / Date `- �7 �'?'j- ,-'7 _ �UH.-�1 j.C+�L] C6YE-Ye l Uh.ILGI� t Additional Commenitl R �O ( �� !h 1 t r ❑ Stk 466-6781 ❑ L di 41!389-3621 ❑ Manteca -7104 �❑ Tracy 5 Applicant- Return all copies to:.,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFOt p� + EH 13-24IREY.I/a5) / p EH 1428 'I ;��3 ,t�_I I O /