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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 �/ , Telephone (209) 466-6781 Wo _ PERMIT EXPIRES S'YEAR FROM DATE ISSUED NIS rL. �( r>� (Complete in Triplicate) . A Application is hefeby 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 weVpump and the Rules and Regulations of the San Joaquin Local Health District. sJ ` f� Job Address ■ City Lot Size PM I t p�h7 Phones/ r?// i Owner's Name IJC�V�d IJ �� Address r � ) I Contractor� Address � � � ��` License No.��Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT _L2__ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS LD.—____ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C UCTION SPECIFICATIONS ED Industrial LJ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing EJ Domestic/Private 13 Gravel Pack racy Type of Casing Specifications FI Public Cl Othe ' '❑ Delta—*----- —'Depth-of Grout Seal-- Type of Grout ' I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by # Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 t Depth 1 Filler Material {Below 50') —_ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is �. ! I� available within 200 feet.) Installation will serve: Residence— Commercial_ Other a i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1 ❑ TypelMfg ---. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: W;ell Fourtid�tion Property,.Line LEACHING.LIN� ❑ No. & Length of lines" "" s Total length/size FILTER BE'd ❑ Distance to nearest: Well Foundation Property Line w SEEPAGE PITS i I Depth t I Size — t Number SUMPS Cl Distance to nearest: Well ��_Foundation Property Line DISPOSAL PONDS ❑ y [-�q 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 Di§trict-_-`" 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 ust call for all re d ' spec' ns. Complete drawing on reverse side. Signed X Title: �' Date: IF DEPARTMENT USE ONLY wf- Application Accepted by 1��_.TAa�, " Date L. �u l Area Pit or Grout Inspection by Dat t Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-fi385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 INFFCK I A OUNT DUE AMOUNT REMITTED CASH RECEIVED BY ! DATE rG PERM 7 NO. +-EH 13-24(REV. sl EH 14-26 �S �VV �,'I �p—��— Ib 0 -1y9 � � r 7777 ed'