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00 � i APPLICATION FOR PERMIT SAN JOAQU€N LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES t'YEAR FROM DATE ISSUED (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 3gCity // Lot Size PM Owner's Name hi b (-len � ZZ y Address d liq.3 f,=..)I'I'1 r zeeej Phone Contractor 4e Address License No. Phone_ I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ R ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP FLD. PROP. LINE \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( ; INTENDED USE TYPE OF WELL PROBLEM AREA C UCTlON SPECIFICATIONS ❑ industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ('I Public 177 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation A Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ e of Pump H,P. State Work Done Well Destru ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION INo septic system permitted if public sewer is 1 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 i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i - 4 SEEPAGE PITS l 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line d 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 t 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." Contractors 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 applica t must ca r all required i spections. Complete drawing on reverse side- f n Signed Title: �,� rb,QA Date: ` 42 � FOR DEPARTMENT USE ONLY yI ti t r Application Accepted by Date �� —r/ Ar 4 f Pit or Grout Inspecti n y Date Final lnspectian bye K4 y� � �� Date 3 13 D ' Additional Comment S tf hce CrOy- 4 ❑ Stk 466-6781 ZLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT RUE AMOUNT REMITTED u1C SH RECEIVED BY DATE PERMIT--NO. FEE+ EH 13-24 iREV.i/n 51 ✓ '.1-�ff�b__ 2~2z-Cl ,R$ 3 EH 14-28 V� ��33