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,, - -- `APPLICATION FOR PERMIT �r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address a K �d! ��L��Cy�',,,.•,,,,� City,6+rY\ Lot Size PM ; Owner's Name S NCLI- �h V 6l Address r7j 6 dt � PhoneC Contractor C Address jsy�c IQ�20U �U.4License No. Phone E OF WELL/PUMP: _ .- NEW WELL..❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AREA CONSTRUCTION SPECIFICATIONS. —.. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications I'] Public F Other Cl to Depth of Grokk'Seal .,- Type of Grout I Irrigation --Approx.,. Depth I Eastern urface Seal Installed by 4 Repair Work Done ❑ Type of Primes H.P. State Work Done. Well Destruction ❑ Well Diameter Sealing Material itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION.LI DESTRUCTION {No sepiic system permitted it public sewer is V" available within 200 feet.) l Installation'will serve: Residence ` Commercial Other` Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity a No. Compartments �^ PKG. TREATMENT PLT. El. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1` r FILTER BED ❑ Distance to nearest: Well Foundation Property Line �/�► SEEPAGE PITS I I Depth Size 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, f 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, 1 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. U [1(' � Signed X Title: Date: ~1 0 E-7 �—(� MZrtiet FOR DEPARTMEf111USE ONLY Application Acceptad,by Date Area �® Pit or Grout Inspecti Date Final Inspection by I �� Date �2 Additional.Comments: ✓(�J 1 ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 CK 0 SH RECEIVED BY DATE PERMIT'NO. 3-24{REV+ EH3 ,C ;5!!',C-%,) -7 EH 14-28 a 7 . ..