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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is he€eby 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 [/ F City 4 ;dr of Size_� QCk1=n, PM Owner's Name Address7. Phone Corltractai ` Q ' �y _- dress -�iJ -° __.�_ -.. U.icense N 7g353 Phone S. 'c"2 TYPE OF WELL/ LIMP: EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,' SYSTEM REPAIR ❑ OTHER ❑ + x DISTANCE TO NEAREST: SEPTIC TANK _ A.D 1VQ SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION _RbhP_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA'r-CONSTRUCTION SPECIFICATIONS ❑ Industrial >COpen Bottom Manteca Dia- of Well Excavationof Dia. of Well Casing-, J Domestic/Private .- p Gravel Pack—_,,,_- D.Tracy Type of Casing t r - .; _ g Specifications t f 1 Public F-. Other f pelta Depth'of Grout Seal Type �Grou AL I 1 Irrigation t �:.ppprox..Depth I Eastern Surface Seal Installed by c Repair Work Done ❑ Type of Pump H.P. , — State Work Done Well?Destruction ❑ Well Diameter Sealing Material (top 50') f Depth Filler Material 18elow 50') ' r TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is �v available within 200 feet./ _ Installation will serve: Residence— Commercial— Other Number of living units: INumber of bedrooms A � T Character of soil to a depth of 3 feet: "`r ` SEPTIC TANK Water table depth ❑ Type/Mfg Capacity--________L___ *No. Compartments 1 - :-_PKG. TREATMENT PLT. El ! Method of Disposal s Distance to nearest: Well Foundation Property Line t LEACHING LINE C] No. & Length of lines " Total length/size ; FILTER BED ❑ Distance to nearest: Well Foundation li Property Line "r SEEPAGE PITS I I Depth Size Number e SUMPS"° ❑ Distance to nearest:- well Foundation Property Line DISPOSAL PONDS El ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws , and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: i �h la an "I certify that in the performance of the work for which this permit is issued,.!shall not employ y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i certifies the following; "I certify that in the performance of the work for which this permit is issued, !shall employ persons subject to workman's compensa tion laws of California." The applicant must aIf for all re wired ins t. r q pections. Complete drawing on reverse si Signed X Title: e Date: If I t FOR DEPARTMENT USE ONLY Application Accepted by e ' Date 11 Area - Pit or�[o ,!nspection-by47164- ; G Inspection by -' _ Dat Additional Comments: r ❑ Stk 466-6781 ❑ Lodi '369-3621 L7 Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 + f FEE AMOUNT DUE AMOUNT REMITTED CK F INFO CASH RECEIVED BY DATE PERMIT'N0, +,EH 14,24(REV.F i x 51 f ) EH 1426