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I 4 APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE LTON AVE.; STOCKTON, CA —'Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE+IISSUED 4 (Complete in.Triplicate). .K 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 r7cll�� ✓ L� "'t:'`� ' ^ ?` � L / 'f - rr —.,City Lot Size PM Owner's Name — Address nn Phon Contractor Address ! ��51� Utl� �Q-� A/ TYPE ZZ OF WELL/PUMP: License No. ! Phone / Z — NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ tr�i.� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private Gravel Pack ❑ Dia. of Well Casing Trac E) Public y Type of Casing�N Specifications ❑ Other ❑ Delta Depth of Grout Seal E3 Irrigation IV-Approx. Depth :. LlEasternTYpe of Grout Repair Work Done ❑ T Surface Seal Installed by JJII Type of Pump H.P. ` State Work Done, Well Destruction Well Diameter ��1 Sealing Material (top 50') 1V �} Depth Filler Material (.Below 50') TYPE OF SEPTIC WO NEW INSTALLATION ❑ REPAIR/ADDITION n DESTRUCTION ❑ (Nos rc system permitted if public sewer is Installation will serve: Reside aCommercial Other av ' le within 200 feet.) _ Number of living units: N er of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT:❑ apacity No. Compartments Method of Disposal Distance to nearest: We Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ClDistanced Distance to nearest: Well Total length/size ation Property Line SEEPAGE PITS ❑ Depth v s 4 Size Number t SUMPS t 1 ❑ Distan to nearest: Well DISPOSAL PONDS p Foundation Property Line 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 employ any person in such manner as to become subject to workman's compensation.laws of Ca tion laws of iforn' lifornia."Contractor's hiring or sub-contracting sgnaltur6'L certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa The applican u or all wired inspections. Complete drawing on rev a side. Signed X Title: C Date: FOR DEPARTMENT E ONLY Application Accepted by _ �g�� Date f�' rea Pit or Grout Inspection by IldM1 Dater i Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 � `�' vex' ❑ Manteca 3-7104 . -a Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA95201 . i FEE AMOUNT DUE AMOUNT REMITTED ; INFO H RECEIVED BY EDATtPERMIT'NO. .+ EH 13-24(REV.i/a 51EH 14-29 .