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APPLICATION,FOR PERMIT E. SAN JOAQUIN LOCAL HEALTH DISTRICT r--- 1601 E. HAZELTpN AVE., STOCKTON, CA "Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR.FROM DATE ISSUED }+ ; • , . ,, , yam!s «. (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 Cid`- Lot Size 4d-ka. PM Owner's Na me --y / �rwr�" Address -�«� .S L -4..r f �. Phone 16� O D SQL T Contractor Address ,% License No. Phone_ TYPE OF WELL/PUMP: NEW WELL Ij WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALFLD.' , LINE FOUNDATION t f AGRICULTURE WELL pT L. PITS/SUMPS INTENDED USE TYPE OF WELL -4--PROBLEM AREA -CONST N SPECIFICATIONS Li Industrial ❑ Open Bottom ET Manteca Pa- of Well Excavation Dia. of Well Casing El Domestic/Private I ID Gravel Pack ❑ Tr Type of Casing Specifications Ll Public. ❑ Other Delta Depth of Grout Seal ❑ Irrigation Type of Grout v� —AP - epth ❑ Eastern Surface.Seal Installed by Repair Work Done ❑ t T of Pump H.P. Well Destruction ! Well Diameter State Work Done E Sealing Material (top So') J Depth Filler Material (Below 50') TYPE CIF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if sewer is Public" - k. i , -.1.. �. Installation will serve: Residence— available within 200 feet.) 1 I Y..-• Commercial_ Other- # Number of living units: Number of bedrooms E �-Character of soil to a depth of 3 feet: E ., SEPTIC"TANK ❑ Type/Mfg Water table depth Capacity' No. Compartments 1 '# PKG. TREATMENT PLT.'❑ F #. Jy Distance to nearest: Well Method of Disposal li Foundation Property Line ti LEACHINGLINE O.. No. & Length of lines FILTER BED Total length/size a.;l J^ ❑ Distance to nearest: Well Foundation E` Property Line SEEPAGE PITS C7 'Depth Size .# ` • ^ SUMPS Number , ❑ Distance to nearest: Well Foundation 'DISPOSAL PONDS ❑ Property Line . r.r 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: "!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: "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." s The applicant mu c II for all r ired i ctions. Complete drawing on reverse side. i Signed X ; S Title:- Date: _ f i FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b Date Final Ins n by Ing Dat Additional Comments: ❑'Stk 466-6781 -❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 6385 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 CK INFO CASH RECEIVED BY DEe7 PERMIT•NO. # + EH 13-24(REV.i/n 5) EH 14-28 �6 ,.�!{"�e•�