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a APPLICATPN FOR PERMIT L"e. SAN JOAQUIN_LOCAL HEALTH DISTRICT 9t.? c jh/Jr 1601 E. HAZELTON AVE.,•STOCKTON, CA dlLlj,.t�. Telephone (209) 466-6781 /amu !- r uy-e- I- fj p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Kc 1.- ' {Completeein Triplicate) j, w�fl.iri Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc bed. This applica#ion i 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 /45-! ! 5- /L City LotSize x PM Owner's Name ;4 IC �^ 2 "" Address �3? K//YjG'S o _ Phone Contractor S2 f Address License No. Phone_ I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER •❑ j DISTANCE TO NEAREST SSEPTt K SEWER LINES DISPOSAL FLD. PROP. LI FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRU CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca II Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ❑ Public '❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation rox. Depth; 0.Eastern Surface Seal Installed by Repair Work Done Type ofPump . I H.P. State Work Done 4 y` ---�Weli-Destructi n ❑ Well'Diamete��""'"�'–°'� Sealing Material (top 50'i "V Depth Filler Material4Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is - available within 200 feet.) 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 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑' No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line T SEEPAGE PITS ❑ 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. 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." _ The applicant st all all uired inspections. Complete drawing on reverse side. Signed X a Title: Date: u FOR DEPARTMENT USE ONLY Application Accepted by Date Area � - Ir Pit or Grout Inspection �{ 1 Date Final Inspection by Date Additional Comments: �–ZL41 ❑ Stk 466-6781 ❑ Lodi 369-3621 C] Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. '+ EH 13-24(REV. y�/�j vI EH 14-28 ._ .-.. e..5-- +....,. . _ Vvu