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P APPLICATION FOR PERMIT 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. ) p Job Address - 4 u" C Az 6 10V.61 City�:ELMkAl Lot Size _/.S_O y 12Z_0 PM Owner's Name L J_ Rq 6 ka Address 31-!!U CeLIW 4Q C hi L Phone _ Contractor izLRl Mk }' SOVA-C Address - 7License No-a5331Phone - 0 TYPE OF WELL/PUMP: IF NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O 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 CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing V \ O Domestic/Private ❑ Gravel Pads O Tracy Type of Casing Specifications C Public . ❑ Other ! O Delta Depth of Grout Seal Type of Grout C Irrigation ----Approx. Depth O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material(top 5(Y) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION / DESTRUCTION ■ (No septic system permitted if public sewer is Installation will serve: Residence A— Commercial_, OjhVr available within 200 feet.) Number of living units: i Number of bedrooms A Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i Type/Mfg E Capacity _/(n 00 No. Compartments PKG. TREATMENT PLT. O � Method of Disposal Distance to nearest: Well Foundation /S Property Line /!2 LEACHING LINE O No. & Length of lines Total length/size FILTER BED ■ Distance to nearest: - Well Foundation /S Property Line /S � SEEPAGE PITS O Depth Size _ Number SUMPS O Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and thar work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heahh District. Home owner or licensed agent's signature certifies the fopowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in sych manner as to become 10ject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: I certify that in the performarfEe of the work for which this pemit is issued,I shall employ Persons subject to workman's corr�pensa- tion laws of California." The applicant must call for all required 'nspecti ns_ Co plete drawing on reverse side. Signed Title: Date: FOR DEPARTM USE ONLY Application Accepted by Final Inspection by Date Date 1p—oZlp— Area /5 Pit or Grout Inspection by Date O 7"4� Additional Comments: C Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REIGINTEDCK INFO �yCASH RECEIVED BY DATE PERMIT NO. d 124(REV. W 1 i B 51 . IA 7 �� ' 74-4-2ti """rr ll _ _— /V•• � V YJ V l