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• � t'1 1J� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , N� (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. c �� Job Address 1 .15' S —Lk City SMKO Lot Size PM t Owner's Name Q91Z, .5 Address 12-6 G-I rWr y Phone q ait- ilk Contractor Neu= Address License No. Phone_ ! TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE r=TYPE OF WELL --PROB AREA CONSTRUCTION SPECIFICATIONS- LJ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing 111 Specifications (I Public 1-1Other f-7Delta " D ' of Grout Seal Type of Grout i I Irrigation —Approx. Depth I 1 Eas rn Surface .I Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50•) 1 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION i I DESTRUCTION (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial— Other Number of living units: Number of bedrooms r i Character of soil to a depth of 3 feet: { Water table depth SEPTIC TANK- x. ❑ Type/Mfg Capacity No. Compartments r (� PKG. TREATMENT PLT. 01 Method bf Disposal v Distance to nearest: Well Foundation Property Line LEACHING LINE L7 J: No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well iFoundation Property Line SEEPAGE PITS I 11 Depth -size Number SUMPS Ll Distance to nearest: Well Foundation f 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. y , 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." T The applicant rhust call for"equiredinns. Complete drawing on reverse side. f r V Signed X_ - _ F �-� TitleR � . - Date: l n^n� FOR DEPARTMENT USE ONLY } i Application Accepted by S XL'M/� i S__ a-,r.t n _ Date �`1 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 2409, Stk., CA 95201 j FE INFO OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH}3-24(REV.i/H 5) S~o 3�• I� (`gS EH 14-28 - [.VVJJ