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0 APPLICATION.FOR PERMIT 6� SAN JOAQUIN,LOCAL HEALTH DISTRICT • 1601 E. HAZEL T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE(ISSUED .�� ' J (Complete,in Triplicate). Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he ein 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. " Jab Address Z �� Cit y Lot Size PM Owner's Name �D .. Address .: Phone Contractor ' �'��i0fle1 � �' Address 1��f License No. __ Phone TYPE OF WELL/,PUIGIP:^ ,; _ NEW WELL ❑ WELL REPLACEMENTy❑'' DES TRUCTIOfV"r❑ . PUMP-INSTALLATION ❑ SYSTEM REPAIR 1© R��t �* OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' s DISPOSAL'FLD. PROP. LINE FOUNDATION AGRICULTURE WELL i OTHER WECL PITS/.SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECACATIONS"' V� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation- �._._ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac T e of Gasin s^ ' Y Type g .._ Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done,--v,1_1 Type-of,Pump " .• -H-p'�-�` - — 4r{—State Work Qone--N r _ Well Destruction EJ Well Diameter "S " ' Sealing Material (top 50') " -- ..,,,_...F"iller-MateriaWBelow 150'1- - _ - - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION IN septic system permitted if public sewer is O available within 200 feet:-) Installation will serve: Residence-y- Commercial Other Number of livingunits: ! Number of b �m�,-3 t Character of sail to a depth of 3 feet: Water table depth' + SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments; PKG. TREATMENT PLT. ❑ Method of Disposal- t Distance to nearest: Well Foundation Property Line _ ! i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ "Distance to nearest: Well- Foundation Property Line r t SEEPAGE PITS )W4�'Depth 2 Size Number SUMPS ;. ❑ Distance to,nearest: _Well _Foundation Property Line 1 DISPOSAL PONDS Li �� f I hereby certify that I have prepared this application and that the work willbe�done in accordance with San Joaquin counTry ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �. x Is, 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 cpmpensatio.n-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." l The applicant must call uir _in`pe Complete drawing on reverse side. s /L Signed ' Title: 1 Date: `7 `3 ar�7 FOR DEPARTMENT USE ONLY 1 Application Acceptedby 49"w"^' Date Area 1 Pit or Grout Inspect1, pate Final Inspection by. Date "lo ,Additional Commen z ❑ Stk 466-6781 ❑ Lodi 1369-3621, ❑ Manteca 823-71m, ❑ Tracy -` Y I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I r FEE AMOUNT DUE AMOUNT REMITTED CK it RECEIVED BY INFO CASH DATE PERMIT'NO. <+ EH 1 -24(REV. F1 5) 90 - - � -7 Q7- EH 144-28 i'lunC7Jf f