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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZEL 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 j 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. — v �Q Cit Lot Size A � AKS PM Job Address Y Owner's Name _��/� /��`- �• G(�o-e/l�� ddress S�10 S` Phone T Contractor_l� cl-%c. CA-&"!1_ Address - r- Zd_eialc(l License No. Phone 3 TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ PUMPINSTALLATION ❑ SYSTEM-REPAIR ❑ ,- ' OTHER ❑ 'MSf TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. SPR^OP-61NE"�( OUNIDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS ��- r INTENDED USE TYPE OF WEL M AREA CONSTRUCTIONS EP CIFiCATIONS 1 ❑ Industrial ❑ Open Bottom Q Manteca I Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ` i (1 Public fl Other Cl Delta Depth of Grout Seal Type of Grout --- I I Irrigation pprox. Depth l I Eastern Surface Seal Installed by _ Repair Work ❑ Type o1 Pump H.P. State Work Done We! estruction ❑ Well Diameter Sealing Material (top 50') E j� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [ 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is d t % available within 200 feet.) { n Installation will serve: Residence Commercial !yOthe.r f� t Number of living units: _ :Number of Character of soil to a depth of 3 fe,�ets ' Water table depth j SEPTIC TANK T pe%Mfg �2a� —7 Capacity ,__ No. Compartments l PKG. TREATMENT PLT Method of Disposal Distance to nearest: 1Vell.`��o` Foundation Property Line LEACHING LINE No.,& Length of lines Total length/size d FILTER BED ❑ Distance to nearest: i Well ��r�:� 'Founaat�on Property Line �V SEEPAGE PITS I I Dep[h i Size _ Number SUMPS s ❑ Distance to nearest: Well Foundation -Property-Line DISPOSAL PONDS F ❑ t 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, nd rules and regulations of the San Joaquin Local Health Diltrict. V 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 applicants must call f(Lr all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �� Date Area Pit or Grout Inspection by Date Final Inspection by Z Date 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, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. +.EH13-24{REV-i i H 5) EH 14-26 ♦✓