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} a e APPLICATION.FOR PERMIT P7j M y` y SAN JOAQUIN LOCAL-HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , •A r (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 Sari 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 / -$ r Li�Ti� City _T t JLot Size PM Owner's Name R, 1 Phone Contractor ! .r �iF Address License No. Phone_ TYPE OF WELL/PUMP: i�. NEW WELL ❑ WELL REPLACEMENT.❑ DESTRUCTION ❑ PUMP INSTALLATION [_1 SYSTEM REPAIR'O' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO OP. LINE FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ra. of Well Excavation ` ` Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tr Type of Casing Specifications ❑ Public El'Other Delta Depth of Grout Seal Type of Grout \l ❑ Irrigation s Depth ❑ Eastern–.,Surface-Seal Installed by " Repair Work Done ❑ Type of Pump H.P. State Work Done._ Well Destruction ❑ Well Diameter Sealing Material (top 501 * I Depth Filler Material {Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION _(No septic system permitted if public sewer is _�� ( available Within 200 feet.) Installation will serve: RAidence Commercial— Other Number of riving units:,' fll Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth r" SEPTIC TANK rr`❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line 9 LEACHING LINE ❑ �� No. & Length of lines j �, g Tota! length/size FILTER BED ❑ ;Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ .Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS ❑ 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 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." ;11 The applicant m st cal for alb require d pections. Complete drawing on reverse side. +' Signed X �. !i cJ e Title: = t '" 41 �J Date: I� FOR DEPARTMENT USE ONLY Application Accepted by IIC� Date" Area Pit or Grout Inspection nl' Date Final Inspection by Date { Additional Comments:- ❑ Stk 466-6781 ❑ L&i 369-3621 ❑ Mante 823-7104 ❑.Tracy 835-6385 Applicant- Return-all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 BOJ INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24 1 REV.I/e 51 !�' _ ,V t3 Q Q EH 14-28 6 z