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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA No LV Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Iv (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 I 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 A-5-6 City Lot Size PM r Ll Y Owner's Name AddressL Phone 14-Corttractor Address. License No. Phone TYPE OF WELL/PUMP: i NEW WELL ❑ ` WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION-❑ SYSTEM REP AI ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM >linmgMaterial ONST CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecaia. Well Excavation— Dia. of Well Casing ❑ Domestic/Private q ❑ Gravel Pack ❑ Tracyy of Casing Specifications F]Public r' C] Other Cl Deltath of-Grout"SealType of Grout _ I Irrigation TApprox. Depth LI Easternurfa Seal Installed byRe air Work Done ❑ 7 pp ype of Pum HState Work Done Well Destruction ❑ WeII Diameter - 245 ftop 50') Depth —__ ILI, Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION,I 1 REPAIRlADDITION I I DESTRUCTIO IN0 septic system permitted it public sewer is .a vailable 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ y Method of Disposal Distance to ne rest ._ lhf IMI n roperty Line LEACHING LINE My have- wit' ❑I No. & Length of line' OPM I length/size FILTER BED ❑ Distance to nearwOrk Wnn Dm.�nl@tedia0as_nPctPd Property'Line SEEPAGE PITS 11 Depth Size umber SUMPS 0 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 DFstrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of tfie work for which this permit is issued, 1 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: "1 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.,'— _ _. __. -,.,,,. ., _ - _ - t The applicant mnsst call for all required ijApecAions. Complete drawing on raver a side. {QSlgned X 0 � Title: __..� �1 _ Date: VVI` PnB-DEPASIMENT USE ONLY Application Accepted by tt date 7:a2—�"�jT Area - f Pit or Grout Inspection b Il�[ Z. �� Yt®?� Pe y _ Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CC 8H RECEIVED 8Y DATE PERMIT'NO. + EH 14�IREV.1/M5) � i�� l/s+C AG�2A� �I�O