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i APPLICATION FOR PERMIT SAN JOAQUIN LOCA. 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. 1B&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address1 l /r' i ,/�G/ City Lot Size PM Owner's Nam Address� l aazr,' f z Phone Contractors c �� Address77 License No. Z__19L Phone TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION El PUMP INSTALLATION LJ REP ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I 1 Irrigation —.-Approx. pth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type o ump H.P, State Work Done Well Destruction ❑ 1 Diameter Sealing Material (top 50'} Depth Filler Material (Below 501 _ TYPE OF SEPT WORK: NEW INSTALLATION I'] REPAIR/ADDITION DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) APInstallation will serve: Residence Y__ Commercial_ Other Number of living units: _L_ Number of bed ooms,. 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg �— Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE IV No. & Length of lines .3 — G Total length/size .a FILTER BED ❑ Distance to nearest: Well Foundation &�� Property Line Z ii SEEPAGE PITS f Depth "L, Size �� .� Number SUMPS D Distance to nearest: Well�Foundation� Property Line DISPOSAL 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 Di"strict. 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "4 certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- tion laws of California." The applicant m t call for all require inspections. Complete drawing on reverse side. Signed �' z Title: Date: G —J Z2 y FOR DEP RTMENT USE ONLY Application Accepted by Date Area�2 J G' -- /Pit/or Grout Inspection lo Date _ Final Inspection by—,, Dat — 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. EH 13-24 ,� ��15� 9 — rI