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Af C _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE.T ON AVE., STOCKT.ON, CA o Telephone (209) 466-6781 . Q PERMIT EXPIRES"1 YEAR FROM DATE ISSUED {Complete in:Triplicate} 7 ` I 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 1 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 ty Local Health District. ' s ; _S T� - 50 KI IS, PM I Job Address27 . V.-1 City Lot Size Owner's Name JST' �>7�t R Address = Phone �� l Contractor WL0 Address f6130 License No.r Z-4V- hone +q3 e { - - f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ D1E ❑ If � PUMP INSTALLATION-❑-. 'OTHER ❑�""""'" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL-F.LD" PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELLw tt PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Oth�af r ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pth ❑ Eastern Surface Seal Installed by --= r Repair Work Done H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 °' 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) I t " Installation will serve: Residence� Commercial_ Other ! 1 Number of living units: Number of bedrooms 4 Charalcter of soil to a depth of 3 feet: - Water table depth SEPTIC;TANK Type/Mfg YCapacity- No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line z _ a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER^BED, ❑ Distance to nearest: Well 'Foundatiiorn Property}Line r SEEPAGE PITS ❑ Depth Size Number 1 a SUMPS 0,,-Distance to nearest:. a Well FoundationProperty 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_Heatth_District. i 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, I shall not t 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:pplicant ust call for all required inspections. Complete drawing on reverse side. Signd X Title: Date: `� I j FOR DEPARTMENT USE ONLY Application Accepted by W Date i� Ares -S Pit or Grout Inspection b Date Final Inspection by Date fi Additional Comments: ❑ Stk 466-6781 -E] Lodi 369-3&1 El Manteca 823-7104 ❑ Tracy 835 6385 I 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 C RECEIVED BY DATE PERMIT'NO. INFO -+ EH 13-24(REV.i/x 5) EH 14-26