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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name)04 Address Phone r . Pa Qo�r�7�7 2Sf'-zz� S A 510_4 5 r Gantract ddress c License No. Phon 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 k _,INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS - ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ! ❑ Domestic/Private ❑ Gravel Pack C1 Tracy t Type of.Casing y. Specifications M Public F Other Cl Delta "Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done `CJ Type of Pump' State Work'Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r! TYPE OF SEPTIC WORK: NEW INSTALLATIO ,REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is "* available within 200 feet.) w _ Installation will serve: Residence 6I Commercial� ther 1 Number of living units: -L Number of a room's._..,, .-.-..-_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK � Type/Mfg Capacity4co o No. Compartments zZr PKG. TREATMENT PLT. 0 ? Method of Disppsal Distance to nearest: Well -L�Q. Foundation Property Line S_ LEACHING LINE No. & Length of tines - " 'Total lehgth7siza FILTER BED0 Distance to nearest: Well N!E� Foundation£ Property Line 4 It SEEPAGE PITS Depth ' Size ` Number SUMPS /❑ Distance to nearest: Well 0r) Foundation s Property Line ElDISPOSAL PONDS _ I 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-thiat 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. hiring hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for-which this permit is issued, I shatl employ persons subject to workman's compensa- -ion laws of California." e The applicant t call for quir .inspections. Complete drawing on reverse si ; Signed X ' Title: I/* �• 'Date 3 FOR DEPARTMENT USE ONLY Application Accepted by Datek. -Area It r Grout Inspection by Date ' Final Inspection by ' _ - DatexRlif?,e` Additional Comments: _ ** ❑ Stk 466-6781 ❑ 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 95201FEE ' 1 g ! INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 - RECEIVED BY DATE PERMIT NO. +.EH 13-241REV. /ns) EH 14 199 20 v { R . 4