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ti APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �_k� r r 1601 E. HAZELTON AVE. STOCKTON CA f i SEP i ! i9m Telephone (209) 466-6781 � ;PERMIT EXPIRES 1 YEAR FROM DATE ISSLW&IRONMENTAL HEALTH 1 -1 (Complete in Triplicate) PERMIT/SERVICES 1' 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 ��Lt.�-_, City Lot Size PM t Owner's Name 19 Address 90B z PhoneVZ Contractor �¢T6�L �, Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACMIENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI_FICAT16NS' '".' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ~� Dia. of Well Casing Domestic/Private .__=❑ Gravel:Pac0 1 "If Tracy Type of Casing Specifications n Public ❑ Other Ll Delta = Depth of Grout Seal Type of Grout )CIrrigation — Approx. Depth I I Eastern Su4ac4 Seal Installed by Repair Work Done Type of Pump,r,QAA�_ . H.P. 4_ 7 State Work Done IV I Well Destruction ❑ Well Diameter �,.-Sealing Material Itop 50'i Depth' ;' z 'Filler Material (Below 501 _ I TYPE OF SEPTIC WORK: NEW INSTAL LATION-(=1-.REPAIR)ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is f . available within 200 feet.) Installation will serve: Residence_ Commercial_ Other i t 'Number of living units: Number of bedrooms y � Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capadity No;Cofhpartments PKG. TREATMENT PLT. ❑ - ,;*'i r Method,of Disposal i Distance to nearest: Well Foundation.. J Property,Line. LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size T Number �._SUMPS . _ , x❑Distance to-nearest: Well Foundation Property_Line_ �,- ___;. DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and that the work will bd'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 subiect to workman's compensation laws of California." Contractot's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for II required inspections. Complete drawing on rse side. Signed X V�/rL Title: Date: !� FO EPARTMENT USE ONLY / Application Accepted by Date !` Area Pit or Grout Inspection by Date Final Inspection by Date 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 K RECEIVED 6Y DATE PERMIT'NO. +.EH 13-241REV.t/n5) ' EH 14-28 3 a