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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 1 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 2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City S )_fw Lot SiZV7_s_ PM Owner's Name - Address _}C__ tJ P4 ,, vV 4� Sfa ! ` Contractor ./ ' " l>'C�� Address �� n 7 `"' License No.�,'U��j� Phono��_ r �� TYPE OF ELL/PUMP: NEW WELL U WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION R SYSTEM REPAIR-1 OTHER ❑ 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 ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation , —_ Dia. of Well Casing L' Domestic/Private 0 Gravel Pack O Tracy Type of Casing _.- Specifications 0 Public ❑Other O Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C Well Diameter Sealing Material (top 501 Depth FiNer Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION O (No septic system permitted if public sewer-is - available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: "Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl 'Method of Disposal Distance to nearest: Well Foundation __ProWiiy Line LEACHING LINE &Length of lines Total length/size J � l�7 FILTER BED LJDistance to a Well—r_ Foundation �j� Property Line'. SEEPAGE PITS _e�— th ' size_ !r Number Dep �.--- SUMPS U Distance to nearest: Well Foundation -_l Property Line DISPOSAL PONDS n 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 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."Contractors 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 Calffornia." _ The applic nt must II fora re,,, ir m tions. Complete drawing on reverse side.SignedTitle:Ci[it U �t! �.�.-r^1 - Date:,, ._ OR QEPARTMENT USE ONLY ^� '. Application Accept9trby 9ea� r gmro�pm& n` Date _. 1.0" Air. J� Pit or Grout Inspection by Data Final Inspection by y_ Date Additional Comments: ❑ Stk 466-6781 O Lodi 388-3621 C Manteca BM-7104 O Tracy 835-6385 ^� Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2",-Silk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO CA - EH 1♦C/ i EH 13-24IREV.,%8:,i - I�O 4b-133a EH 1426