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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED j !Complete in Triplicate? I4 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 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Aom y A" City Lot Size PM Owner's Nami, Address 046i=AuG(/ Phone Contractor �+t- ddress �e License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA:.�rS�POSAL OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FLD. PROP. LINE \ FOUNDATION AGRICULTURE WELL� OTHER WELL PITS%6UMPS INTENDED USE TYPE OF WELL PROBLEM AREASTRUCTION SPECIFICATIONS Q ❑ Industria! ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing *� ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing Specifications �\ Fl Public fl Other Delta Depth of Grout Seal Type of Grout I I Irrigation �_Appr . epth I I Eastern Surface Seal Installed by Repair Work Done ❑ Typ Pump H.P. State Work Done Y Well Destruction ❑ ell Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPT1rC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence-A Commercial— Other Number of living units: 1 . + ' Number of be rooms / Character of soil to a depth of 3 feet: Water table depth �G SEPTIC TANK Type/Mfg4r1_-XZCapacity No. Compartments PKG. TREATMENT PLT. ❑ I k Method of Disposal / Distance to'nearest: Well Foundation Property Line 1 LEACHING LINE rC4 No. & Length of lines Total length/size X i FILTER BED ❑ Distance to nearest: Well fl'G Foundation / f Property,Line J SEEPAGE PITS i I Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Litre DISPOSAL PONDS El 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 li 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: '9 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 mus all for all req sod inspections. Complete drawing on reverse side. A!, !//f Signed X � Title: FOR DEPARTMENT USE ONLY12- / Application Accepted by Date `�` �' Area Pit or Grout Inspection by Date Final Inspection by r ti Y Date7-, r Additional Comments: d!" ��/' 44- !r 0e — 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH13-24 IREV.1/a 5) EH 14-28