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APPLICATION FOR PERMIT , ' 1 SAN JOAO.OIN.-L'OCAL HEALTH DISTRICT j 1601'E. HAZELTON AVE., STOCKTON, CA Telephone 12091466-67$1 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' ' I (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 AddressZ-5 City Lot Size ACRE PM r Owner's Name it 1 ri'�1hT.l'Sr - Address ,= � �.� ��- Phone 'Contractor '+ itQ Address —'License No. Phone_41' TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT.O DESTRUCTION ❑ 14#"_ I — 4.r N PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ + "OTHER ❑ 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 L Dia. of Well Excavaticn a ,Dia. of Well Casing ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing r t Specifications (`l Public 1`7 Other ❑ Delta ` Depth of Grout Seal Type of Grout _ I I irrigation _.-Approx.�Depth I 1 Eastern Surface Seal Installed by s Repair Work Done ❑ Type-of Pump * H.P. Z 5tate.Work'Done ; Well Destruction ❑ Well.-Diameter _ 4 ` Sealing Material (top-501 Depth # Filler Material (Below 501 TYPE OF SEPTIC WORK:'. NEW INSTALLATION' a; REPAIR/ADDITION l"]'" DESTRUCTION I i (No septic system-permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceCommercial_= Other . n ~Number of living units:,V Number of bedrooms z Character of soil to a depth of 3 feet: t. U Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity 1U No. Compartments E PKG. TREATMENT.PLT- ElMethod of Disposal y r: F „r - ,, Distance to nearest -Well Foundation Property Line LEACHING LINE, r� No & Length of litres Z` L X �� Total length/size __f .:' • d FILTE�R�IBrED ❑ Distance to nearest':-- Well ld� Foundation Property Line 17 C+ - # SEEPAGE PITS 11 Depth Size i Number SUMPS, ❑ ,Distance to nearest: Well Foundation Property-Line DISPOSAL PONDS ❑ 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`:A 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."'-. applicant sus call for all required ' s tions. Complete drawing on reverse side. Signed- r -TifEe: C/ Q Data: rE F EPARTMENT USE ONLY Y- + Application Accepted by Date! Area Pit or Grout Inspection by / Da Final Inspection by Date Additional Comments:. _ Ifri..r1�42`s�'��'�i 'f{1�t�,r ❑ Stk 466-67$1 ❑ Lodi 369-3621 wf Manteca ,017104 ❑ T cy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f S P i INFO AMOUNT DUE AMOUNT REMITTED GA R- RECEIVED lay y DATE PERMIT-NO. (' + EH 13-24(REV.I/As) �{_�d { EH 14-28 �v `