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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 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. _ 9 Job Address S 14,4 5 City 5 0!; �Lot Size qJ x i i D PM Owner's Name 69 SL%JA-fJ1,0AJ Address �Sq1 .57/446777 Phone Contractor Address UQ �L License No. Z �Z Phonelq3M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELT PITSISUMPS—, ---------------------------------------------------------------------------------- INTENDED USE PROBLEM AREA CONSTRUCTION SPECIFICAT16NS L1 Industrial ❑ Open Bottom ❑ MantecaIf Excavation Dia. of Well Casing ., ❑ Domestic/Private ❑ Gravel Pack E ❑ eye Type of Casing Specifications ❑ Public ❑ Other ❑ Delta ° Depth of Grout Seal Type�af Grout i Ll Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Wor E7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material iBelow 50') TYPE OF OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public seweris available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK . ❑ T e/Mf I Yp 9 `Capacity No. Compartments PKG. YFi[ MF. T. ❑ Method of Disposal Distance to r ell Foundation Property Li LEACHING LINE ❑ No. & Length of lines o h/size FILTER BED ❑ Distance to nearest: F77Number Property Lr SEEPAGE PITS �E] Y Size SUMPS �Distf,,to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 1 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."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 applicant must call for all requ"ed i apections. Complete drawing on reverse side. Signed Title:---I i�wm eDl ate: FOR DEPARTENT USE ONLY Application Accepted by Date " Area r Pit or Grout Inspection by Date Final Inspection by Date it;. 7 Additional Comments: i 't1 / Ll Stk 466-6781 ❑ E�369 E3621 ❑ Manteca 823 7104 racy 835 [�./ f 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 RECEIVED BY DATE PERMIY NO. INFO CASH + EH 1 -241REV.7/n5) EH 144-28 r•� .�J �"! I