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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZELTON 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 Sen 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. + 4c��' Job Address City k o f Lot Size I<" PM Owner's Name x J...- C`I I f1 Address �0 N A!n L.a r•'r_ Phone k r Contractor's Name License No. Phone TYPE OF /PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑. DESTRUCTION ❑ v j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑` OTHER DISTANCE TO NEAREST: SE NK SEWER LINES +. DISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL C CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom __0 Mantec + ,'- elf-Excavation Dla. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications x ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - J ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Type of Pump ` H.P. State Work Done 1 Well D ction ❑ Well Diameter Sealing Material ftop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial 1e Number of living units: Number of bedrooms 1 a Character of soil to a depth of 3 feet: Water table depth { SEPTIC TANK Type/Mfg 4- ,- Capacity rte._. No. Compartments PKG. TREATMENT PLT, Method of Disposal JI Distance to nearest: Well no, Foundation__,.�_ Property Line LEACHING LINE No. & Length of lines 4' _ m �,� 9 Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation' Property Line t + SEEPAGE PITS ❑ Depth Siz Number SUMPS ❑ Distance to'- Foundation Property Line DISPOSAL PONDS '' f 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a d rules and regulations of the San Joaquin-Locai Health District. Home owner or licensed agent's signature certifies the following: "I 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: "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." ., f .y The applican must call for requir d inspections. Complete drawing on reverse side. }; Signed Title: W V e� Date: FOR DEPARTMENT USE NLY y Application Accepted by -Date JU"` 0— Area Pit or Grout Inspection by Date 1 'F al Inspection by m ; Data Additional Comments: Aee &T— /! Ile ❑ Stk 466-6781 ❑ Lodi 369-3621 F ❑ Manteca 823-1104 ❑ Tracy 835-6385'» ".,/;b OrP/~O ;MCrWW47 dsC /y Applicant= Return all copies to: Environmental-Health Permit/Services 1601.'f.-Hazelto6 Ave:, P.O.-Boz 2009, Stk.; CA 95201 FEE INFO AMOUNT DUE AMOUN�T�RREEM'IITTED . CK 'RECEIVED BY �) DATE PERMIT'NO. +EH 1324 IREV.10!$31 EH 1426