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TION FOR PERMIT y APPLICATION _ ---- i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 n R PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 00" Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des�ed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City OG ��LotSize PM Owner's Name `��i4ldd e C 4-dl- �J 7- Phoneg ` Contractor_ �� Lr Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT CIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Mapteda� ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications 1'1 Public ❑ Other alta Depth of Grout Seal Type of Grout I I Irrigation _.._.Ap epth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ e of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50�) TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITI.ON I I DESTRUCTION I INo septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence____ Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: ,Well; Foundation Property Line � a . LEACHING LINE ❑ No. & Length of lines Ilk Total length/size FILTER BED ❑ Distance to nearest: Well Found tion Property Line SEEPAGE PITS Depth Size " . Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ !r- "�""�"""`"" i I hereby certify that I have prepared this application and that the work will be done insaccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. `— ! f Home owner or licensed agent's signature certifies the following: "I certify that in theierformance 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 Caijfornia.y 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 aT1T6r ' ' The appli n u call for all re i in tions. Com late drawing on reverse side. } Signed t Title: II Date 'eZ FOR DEPARTMENT USE ONLY i 04 Application Accepted by Date Area - Pit or Grout Inspection Date Fina! Inspection by Date�^ Additional Comments: r 6 / F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca%823-7104 k ❑ Tracy -835- 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Al- RECEIVED BY DATE PERMIT NO. ' + EH 13-24 IREV.1 i H INFO 51 J 2 EH t4-ZB 4��