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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091466-6781 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address �Vneo ter Af/c Chy&tx<toaot Size PM 0C k7t210 Owner's Name i lr�,�0�� V�.��l. -ndress s r Phcne J Contractor.� E Address 5wm c- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTA LATION ❑ SYSTEM REP OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP. LINE FOUNDATION AGRICUL WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL ROB REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tr Type of Casing Specifications it Public ❑ Other F Delta ' Depth of Grout Seal Type of Grout I I Irrigation x. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Dona_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAIR/ADDITION I I DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 2� Commercial_ Other Number of living units: / Number of bedrooms Character of soil to a depth of 3 feeti'` Alcmali Water table depth �i�A2C#<C77� Capacity 00 No. Compartments Z SEPTIC TANK _-Z Type/Mfg _ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line In LEACHING LINE ❑ No. & Length of lines- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Il Depth —Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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; "1 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 became 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 required i pactions. Co late drawing on reverse side. Signed X n Title: ✓��- Date: �- �. FOR DEPARTMENT USE ONLY / -Application Accepted by Date - 1 —Ae Area Pit a Grout Inspection Date (Final Inspection bbyy'�'`�- 0a,'e / Date Additional Comments: 1V �e-- l3 Jt rr d't G ! Qom. 6/4t �id�L4t�. ❑ Stk 488-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ tracy 835-6105 Applicant - Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNTDUE AMOUNT REMITTED x RECEIVED BY DATE PERMIYNO. INFO •.ER 13-24IREV.i/x3) 3�� `mss. q-► 3-x� a3 ER I4Z