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1 3`4/2r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601�E,�HAZELTONS�AIIE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 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. p Job Address �U / /.�i� 0 ity , C. Lot Size PM Owner's Na *' E2 e, !S/e--CS1,0� Address Phone Contractor LW7ress Q r License No. CJ one TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONr i+SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK _ .-SEWER GINE$: DISPOSAL FLD. PROP. LINE ; FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CbNSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing 1,d 's +Dm oestic/Private 1:1Gravel Pack ❑;Tial cy � T __ s y ype of Casing Specifications ❑ Public ❑ Other ❑}IYe-tta epth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑Ea rr1""F---Surfs a Seal Installed by z` Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia!`4top'50'I 1,44 ' Depth FiIWC—Vlaterial dBelaw 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic stem ` p y permitted i#public sewer is 46 available within 200 feet.! if Installation will serve: Residence__. Commercial Other ~ 0 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth / SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size Y FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 1 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 Joaquin Local Health District. Home owner or!' nsed agent's s nature certifies the fol ing: "I certify that in the performance of the work for which this'permit is issued, I shall not i> employ any p on in such mann as to beco subj to o man's compensation laws of California." Contractor's hiring or sub-contracting signature f[d certifies the ollowing:"I certify in th pe a e o he ork for which this permit is issued, I shall employ persons subject t6wowkman's compensa- tion laws California 11 ' L The app ant m II 1 equir i omp to drawing on r r Signed Title: Date: F R DEPARTMENT USE ONLY Application Acceptedb Pate res Pit or Grout Inspection y Date Final Inspection by Date 'f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'`NO. + EH 13-24 IREv.1/a 5) EH 14-28 • C�]E� —