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rr APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for weil/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ..- City Lot Size - PM Owner's Name Address', Phone Contractor -= - 0_0,p.L dress License No. Phone W ® `(V \ TYPE OF WELL/PUMP: NEW WELL'❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR 0 ❑ DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPO D. PROP, LINE 4 FOUNDATION AGRICULTURE WELL: HER WELL PITS/SUMPS . INTENDED USE TYPE OF WELL PROBLEM AREA C UCTION SPECIFICATIONS. } ❑ Industrial i ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation. Dia. of Well Casing ❑ Domestic/Private, ❑ Gravel Pack cy Type of Casing Specifications O Public ` i ❑ Other ❑ Deltas Depth of Grout Seal Type of Grout I ❑ Irrigation i prox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. StateWorkHone Well Des on El Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 F^° %:=TYPE OF SEPTIC-WORK: ..NEW INSTALLATION-El- REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence commercial-�o:Other Number'of living units: _� Number of bedrooms Characterofsoil to_a depth of_3 feed: Water table depth 76/ SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments PKG"'TREATMENT PLT. ❑ Method"of D' sal '' Distance'to nearest: Well .rte Foundation Property Line. F^ - LEACHING LINE ❑ No. & Length of lines IaLt` Total length/size 1 FILTER BED—0" Dis`"tance to nearest: 'Well—/- Foundation C _ Property Line SEEPAGE PIT_S ❑ Depth X 6e t Number 19, r i { y ❑ Distance to nearest: Well � Foundation iW___-~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 t 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 applicant us for a uired ctions. Comp) a drawing o verse side. ` + .0,Z/ �vt r, Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date -7 Area �r/►'r3� (l J�vt or Grout Inspection by Date j a Final Inspection ' ! r Additional Comments: i2�$_k7 SZ.w,y" ��srr u� �• a�s tea f C,l,/��ref 6e a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy , `, ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE (NFD AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. + EH 13-244REV,i/a5) EH 1418 r1ca—