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r � APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDi (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �.Z S �� C�k PZe City Lot Size Z iii )e,306 PM Owner's Name3" �6 S`t d�(fk Address ✓� � Phone ` r Z Q.7�v ContractorG ` I �d G1 Address License No.qaac�Phone —y11Sz X TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 ❑ Tracy Type of Casing Specifications 17Public EDOther p Delta Depth of Grout SealType of GrolGf LlIrrigation �4pprox. Depth 1:1Eastern Surface Seal_Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION P1 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -available within-200 feet.l Installation will serve: Rest ence Commercial_ ther Number of living units: Number of bedgams Character of soil to a depth f 3 feet: Water table depth SEPTIC TANK L9' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f - - Method of Disposal Distance to nearest: Well U Foundation DC7 Property Line LEACHING LINE X No. & Length of lines Total length/size "L� FILTER. BED ❑ Distance to nearest: Well_�QQ_ Foundation Property Line SEEPAGE PITS Depth `�'! � _Size b Number SUMPS ❑ 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 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 laves of California." The applicamus call for all requ' pections. Complete drawing on r verse side.IRV Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area O Pit � ttl spection y Date Final In pection by Date Additional Comments: A Stk 466-6781 ❑ Lodi 369- 1 --ff Manteca 823-7104 ❑ Tr cy 835- 5 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 A RECEIVED BY DATE PERMIT NO. + EH 13-24 MIEN.iia51 EH 14-28 '2',,'2',, 1� C & 1