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3APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED I (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 I 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. I�I i Job Addr p Ci Lot Size PM Owner's ��""►`*r Address �` [ADE(j�C of Contra or 3 (br�f� r ess' License Imo? t TYPE OF WELL/PUMP: lY, `' �Phone {} II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONt l I SYSTEM REPAIR C3 OTHER ❑ 1 t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LAVE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' is/Private ❑ Gravel Pack ❑ Trac T Dia. of Well Casing Y Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I ❑ Irrigation JI a Type of Grout ' pprox. Eastern rfac eal w�talled by, I Repair Work Done ❑ Typei of Pump H.P. J State Work Don �T ; Well Destruction ❑ Weli�Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system i permitted if public sewer is r available within 200 feet.) Installation will serve: Residence— Commercial_ Other r Number of living unitNumber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I i PKG. TREATMENT PLT. ❑ 11 Method of Disposal }y E Distance to nearest: Well Foundation Property Line { " it - LEACHING LINE ❑ No. & Length of lines length/size. 1 FILTER BED ❑ , Oistance'to nearest: Well Foundation 4 Property Line SEEPAGE PITS ❑ Depth Size Numbers } i SUMPS ❑ Distance to nearest: Well Foundation �Prop' " erty Line ^" 1 DISPOSAL PONDS C11 > I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances) ate laws, and,.„,. rules and regulations of the San-(Joaquin Local Health District. Home owner or licensed agent's signature certifies the followin employ an g: "I certify that in the performance bf the work for which,this permit is,issued, I shall not P Y Y person in such manner as to become subject to workman's compensation laws of Califorria.""Contractor's hiring or sub-cbntracting signature certifies the f o ing:"I certify that in the rlor ance o he work for which this permit is issued,i shall em to tion laws of alt rnia.” j PrP Y persons subject to workman's compensa- tion The applic t t call for r .I uire i c s. Co (Mete drawing o rve side. I° Signed ! r Title: Date: _ FOR DEPARTMENT USE ONLY j Application Accepts by . Date / Area �� -.r.� Pit or Grout Inspect y -- -_Date Final Inspection by __ __ Date Ad! �ditionaE Comments: T �–.- ❑ Stk 48B 6781 ❑ Lodi :369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 f 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 INFO CASH RECEIVED BY DATE PERMIT NO. CK 4 + EH 14-25 EH 3-24 cob t/e 57 I�.cob C� - ! J[