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y � E _ t APPLICATION-FOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t"p-0 kly-r-��>i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) {� Aication Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her n desccribed. T� ht 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 City - Lot Size PM f Owner's Name Address ,� - Phone �T _ w rf Contract Address G E_icense ? Phon� 26kv TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTUREWELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM:AREA CONSTRUCTEDTIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca_ D, ell Excavation Dia. of Well Casing G 4=❑ Domestic/Private ❑ GravehPack ElTr s i Type of Casing ) Specifications -n ; 4 v3 W I 1 Public F] Other Delta `4 -Depth-oi Grout Seal Type of Grout I i Irrigation pprox. Depth i I Eastern t Surface Seal Installed by q Repair;,Work Do Type of Pump H.P. State Work Done ._Well D tion E3 Well Diameter Sealing Material (tap 50') f } _ Depth t Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I.l' REPAIR/ADDITION I I DESTRLICTION INo septic system permitted if public sewer is a available within 200 feet.) Installation will serve:' Residence]—' Commercial—_Other, Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth `SEPTIC TANK- '❑ Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT. ❑ b Method of Disposal Distance to nearest: Well t Foundation Property Line LEACHING LINE ❑ No. &Length of lines ' g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation = Property Line SEEPAGE PITS I i Depth Size Number SUMPS ❑ Distance to nearest: Well E Foundation Property Line DISPOSAL PONDS ❑ a 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."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." I The applicant ust call for all requilw inspect( ns. Complete drawing on reverse side. Signed X Title: l� � � Date: el't (Ar MENTUSE-ONLY'—'--�! -"1 .f �] Application Accepted by thl( OL�� + � hoc1, y Date (a�L�� ` T Area pe -Date- �.,".', !t d p y� —gmd4 Date P Pit or Grout Inspection by Dateti� Final Ins action b Additional Comments: I' Ll Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK Hp RECEIVED BY DATE PERMIIT'NO. Ilk, + EMI 34-2824 tREV.i/h 51 � .G S , ��Q!� � �/�''�S •'"•L 4@ T� 1� I EH 1 + l