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APPLICATION FOR PERMIT In SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA F Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) App6cation.is hereby made to the San Joaquin Local Health District for a permit to construct andlot 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 k Local Health District. i l Job Address o0 A E- A" __ City Lot Size PM QLA Owner's Name U..�.K / Address 1© Phone—'�5 y ' t -s- -, 10 Contracta� Address --0 ), License No. Phone 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 WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC710N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing C3 DomesticlPrivate ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications F! nPublic F1 Other Ll Delta Depth of Grout Seal Type of Gfout ! 1 irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done © Type.of Pump H.P_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth =4=L9Z r Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [] I REPAIR ADDITION l DESTRUCTION I I (No septic system permitted it public sewer is -available within 200 feet-) Installation will serve: Residence— Commercial x_ Other – +� Number of living units: Number of bedroorps Character of soil to a depth of 3.feet: Water table depth C " SEPTIC TANK 0 'TypelMfg Capacity No_ Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of(fines Total length/size F FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAG€PITS IA-,Depth Size _ �J�_ __ Number k F z SUMPS ❑ Distance to nearest: 1NeU } Fqundation Qi `ti' _ Property Line rt' DISPOSAL PONDS ❑ _ I hereby ceriify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and. r rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "!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:`1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa F, tion laws of California_" The applicant ust call fo II r aired inspections'. Complete drawing on reverse sid Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date�/f_ _k Area or Grout Inspection by -E� Y 't1Aa e , Final Inspection by v ' Additional Comments: 0 Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_, P.O. Box 2009, Stk., CA 955201 , FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMl7 NO. INFO CASH PtEH13-24(REV.tin5) p EH 14.26 / 6 +