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r Za i APPLICATION FOR PERMIT D SAN JOA u QUIN LOCAL-HEALTH DISTRICT �, , 1601 E. HAZELTON AVE.; STOCKTON, CAL( `` ¢� Telephone (209) 466-6781. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH - x _:.; (Complete in Triplicate) EERMiTAERVICES ' 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 Sari 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 [ '7, 7 T ��prY-'I'� _.City Lot Size PM Owner's Name _ _a�Ct CrfCrf _ j 1� Address Phone Contractor ' J�P(r l�rl f✓��1 Address f!V �. f(l/i- Y License No. 1- Phone �- 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑1 SYSTEM REPAII,❑ OTHEJ9 ❑ ! 1 DISTANCE TO NEAREST: SEPTIC TANK -1&(2 SEWER LINES DISPOSAL FLD.7 a� PROP. LINE FOUNDATION. -AGRICULTURE WELL.- OTHER-WELL.--I PITS/SUMPS,-.. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS ❑`Industrial ❑ 0 an Bottom ❑ Manteca Dia. of Well Excava ' Dia. of Well Casing �J L�Domestic/Private ;ravel Pack 'Tracy Type of Casing Specifications Q� rrr❑"'Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 9�+e ❑ Irrigation ��—Approx. Depth ❑ Eastern Surface Seal Installed by f I r Repair Work Done ❑ Type of Pump H.P. State Work Done [� Well Destruction Cl Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet.} Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ater table depth SEPTIC TANK - ❑ Type/Mfg Capaci o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We I F ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: I Foundation Property Line 4 SEEPAGE PITS ❑ Depth Size Number SUMPS_ ❑ Distance to near est: .r Well Foundation .P►op e.rtYLine x DISPOSAL NDS F1 '- �. 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."Contractors 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 applicant all for lire it inspections. Complete drawing on re side. Signed Title: Date: r� FOR DEPARTMENT USE ONLY ]o� q l Application Accepted by Date I f G Area 1 O Pit or Grout Inspection by to Finalspec'on by Date Additional Comments: 7 [I Stk 466-6781 ❑ Lodi 369-3621 a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT''NO. INFO CASH a EH1 -241REV.7/e5} _ ^' EN 1428