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APPLICATION FOR PERMIT D � � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 MAR 29$x ` PERMIT EXPIRES TYEAR FROM DATE ISSUED EN;,�iRC-';;,.1;`IR=�:i,vl-�i Ii�ALTI� {Complete in Triplicate) i-1E[-!!1'l SE VCES 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 /i ALMCity Lot Size PM f Owner's Name /- X–ALIA�_4' / Address Phone t "199 �j) -�}�, Contractor Address. 1 /0-Aef) LGD License fEo. Phone k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ j DESTRUCTION ❑ PUMP INSTALLATION �YSTEM REPAIR ❑ Y OTHI R ❑ . DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLO- PROP. LINE M �. FOUNDATION AGRICULTURE WELL OTHER WELL "PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f } 1-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' Dia._of.,Well_Casing f .._�omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications , r - F1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout — I Irrigation - —.Approx. Depth I I Eastern Sufi co Seal Installed by Repair Work Done ❑ Type of Pump H.P. 14Z= State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 0 available within 200 feet.) - w 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 y I PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line = r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth Size Number SUMPS"" CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 DF%trict. j. 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." r The applicaln aj Complete a uired i drawing on rev rse side. Signed X � � Title9 Date: 4 k FOR DEPAR MENT USE ONLY Application Accepted by `T� _ Date Area �� l Pit or Grout Inspection by Date— Final by f�h Date Additional Comments:' ' ❑ Stk 466-6781 0.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, Stki, CA 95201 FEE CK 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a.EH 1324 MEV.i/851 EH 14-26 �+�� l