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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209}-466-6781 PERMIT EXPIRES TYEAR 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. Job Address �P/ F �'N Y City Lot Size PM 0 ,f Owner's Name DGS Address Contractor �' Address +��a S,'�J'� �4 �� License No. Pho 'e TYPE OF WELL/PUMP: �I „NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �"D4tP�7►TG PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEP�IC TANK H4 SEWER LINES :F �..__ DISPOSAL FLD. f_'. ROP. LINE FOUNDATION _ Z AGRICULTURE WELL�3� OTHER WELL_ PITS/SUMPS INTENDED USE Y TYPE OF WELL PROBLEM AREA CONSTLUUgTIQN SPECIFICATIONS (71 Industrial ❑ Open Bottom ❑ Manteca Dia. of;11Excavation , Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑,Tracy Type of Casing _ Specifications 1'1 Public ]ii(Other_'06V-n4U161.1 Delta Depth of Grout Seal 'y`� Type of Grout �V _ I I Irrigation #5jpprox. Depth l I Eastern Surface Seal,lnstalled by �1I r Repair Work Done E] Iype..of Pump H.P. State Work Done Well Destruction ❑ Wel [Diameter Sealing Material (top 501 Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: -NEW INSTALLATION 1.) REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence_____ Commercial Other .... ._ G Number of living units: �! Number of bedrooms _ I: Character of soil to a depth df 3 feet: 4 Water table depth i. SEPTIC TAMC ❑ Type/Mfg "'Capacity No. Compartments' PKG. TREATMENT PLT. ❑ �I� Method of Diosal Distance to nearest: Well Foundation Property Line C E ENT ` j LEACHING LINE Cl No. & Length of lines Total length/size .I. r FILTER BED ❑ Distance to nearest: Well FoundationProperty Line V 1888 i SEEPAGE PITS I-1 r epth Size Number ON 4ENIlr r HEALTH SUMPS L� Distance to nearest: Well Foundation Property Line PERASERVECE$ H DISPOSAL PONDS 1:1 11: hereby certify that I 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: "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." The applicant st II for all rpq ins o" ns. eta drawing on reverse side. Signed X II Title: � �-_ Date: + FOR DEPA TMENT USE ONLY 1 j Application Accepted by awC4 C'-A-, ,Date Z3 L Area Pit or Grout Inspection by Date a +° Final Inspection by Date Additional Comments: ❑ Stk 466-6781 i ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies tor: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 0 CASH + LH 13�241REV.1/N5S 5 -Qb � [g--a3-� 88-ls�s .. EH 14-26 IM — 1