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ES APPLICATION FOR PERMIT SAN JOAQUIN.-LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.;':STOCKTON, CAS i t Telephone (209) 466-6781 a PERMIT EXPIRES�'I YEAR FROM DATE ISSUED r =' ,,., � ,:�:� •' ,'-.„1 (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 I l p �/��O C 1`P - City Lot Size /S O S PM Owner's Name Address -CAl R aN I C L Y° Phone y�2 Contractor J C.` _ _ _Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE FOUN AGRICULTURE WELL OT PITS/SUMPS INTENDED USE TYPE OF WELL ' '6 PROBL C TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantee Dia. - ell Excavation. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation rox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ - ype of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is „ v available within 200 feet.) Installation will serve: Residence— Commercial_ Other S 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 l PKG. TREATMENT PLT. ❑ Method of Disposal . Distance to nearest: Well Foundation eProperty Line LEACHING LINE ❑ No. & Length of lines ' =.Total length/size FILTER BED ❑ Distance to nearest: Well Foundation "Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearesC 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. i_- - — s 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 F 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." q ' T ant must call for all required inspections. Complete drawing on reverse side. x, Signed X 4-✓t l.c �L— Title:. ey_1/1_� � Date: Li ib n FOR DEPARTMENT USE ONLY Application Accepted by Date — Area (� / pp Pit or Grout Inspection Date Final Inspection by Date ) _D—] Additional Comments: i ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 8i0l 04 ❑ Tracy 835- 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24I EH 10.29 REV.sin51 �'Y'1 �-Uti.y y.3� ,U� C, 5.•� IL ' a O 1 f lam? ✓✓✓`'�� -