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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 2_ 1601 E. HAZE T ON AVE.,-STOCKTON, CA f� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED (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. Job Address tAl �p .City Lot Size PM Owner's Name --Address iyvL�P _ - `Phone f'd Contractor Address License No.� Phone TYPE OF WELL/PUMFFNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i a PUMP LATION [I F SYSTEM REPAIR`❑ OTHF�II� i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES: DIS D. PROP: LINE FOUNDATION A TURF WELL OTHER WELL PITS/SUMPS f 1 INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well vation Dia. of Well Casing C1 Domestic/Private C1 Gravel Pack racy Type of Casing Specifications L] Public O Other LJ Depth of Grout35eal Type of Grout F-1Irrigation _Ap . Depth ❑ Eastern Surface Seal.Installed.by s Repair Work Done ❑ of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50',)' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is rn * available within 200 feet.) 1 Installation will serve: Residence— Commercial! Other F Number of living units: Number of bedrooms t .` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments El _ I PKG. TREATMENT PLT. t_ -�.<- ° �,--,--.-_-_ ----- , Method of Disposal.f ! Distance to nearest: Well Foundiation Property Line__ f LEACHING LINE ❑ No. & Length of linesY Total length/size ` t FILTER BED ❑ Distance to nearest: Well Foundation i Property Line I I i I SEEPAGE PITS ❑5. Depth Size i Number I y 11 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. ; 1 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 licant call for all required ' cti ns. Complete drawing on reverse side. Signed r Title: Date: FOR DEPARTMENT USE ONLY 43 - / - o Application Accepted by Date Area d. ' ` Pit or Grout Inspectio y Date Final Inspection by � Owe Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE cA�MOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO -C . + EH 13-241REV.l/H57 p�- r� EH 1428 ✓•.� j� r (VYY�