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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 --,oafI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��' s s: (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 L 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 {I Local Health District. I Job Address _ .+ \� / Q� City SAI_— Lot Size PM Owner's Name CAArker�i1 e ! Address cZ '� � �� Phone "vZ Contractor t Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Jv'-DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANC EAREST: SEPTIC TANK SEWER LINES SPOSAL_FLD. PROP. LINE FOUNDATION AGRICULTURE WELL_ ^Fr _,OTHER WELL PITS/SUMPS _ INTENDED USE TYP ELL PROBLEM AREA CON CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca is. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ r Type of Casing Specifications ❑ Public ❑ Other ❑ a e th.of Grout Seal Type of Grout ❑ irrigation �Approx. Dept ❑ Eastern Surface Installed by ' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Fifler Material (Below 501 : TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO INo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of r Character of soil to a depth o feet: Water table depth SEPTIC TANK X Type/ i t, r yPe i� a city No. Compartments 11 � PKG. TREATMENT PLT. aVe expired WIthOU# r Method of Disposal Distance to nearest: aF unda 'on roperty Line I W(�r COM �elea or I 1 _"d LEACHING LINE ❑ No. & Length of 1' �ngth/size FILTER BED LI Distance to are t: Well Fou tion Property Line SEEPAGE PITS D th Size umber SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a 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."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." ' v 111 � LI f The applicant must call for all required ' ctions. Complete drawing on reverse side. V Signed Title:' Date: o+Z (f l ., FOR DEPARTMENT USE ONLY +� Application Accepted by `�"�. ,Date p Area Pit or Grout Inspection r ` jrl� {�G h ►Ytp` c` Pe ' Date Fin I Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36121 ❑ 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 INFO AMOUNT DUE ' AMOUNT REMITTED CK CA5H RECEIVED BY DATE' PERMIT NO. + EHt3-241REV.tie51 L.� �� U -yl�� EH 1428 q/ f