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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZE T ON AVE., 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, Job Address 5V11 Com" / �� F � F — City � � Lot Size PM Owner's Name jam} Address fJ Phone Contractor's Name jai kJ�"Yfes Ljcense No. 9Y Phone ;k-]R ' y� TYPE OF WELL/PUMP: . . NEW WELL ❑ WELL REPLACEMENT. _ --.. DESTRUCTION.❑ _ PUMP INSTALLATION - ❑ OTHER ❑ 5 -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t`- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E -INTENDED-USE TYPE OF-WELL -PROBLEM-AREA -CONSTRUCTION'SPECIFICATIONS- -�-�-- - ❑ Industrial ❑ Open Bottom Dia. of Well Excavation i Dia. of Well Casing ;KDomestic/Private. Gravel Pack ❑ Tracy Type of Casing_ Specifications ❑__Public 10ther ❑{Delta Depth of Grout Seal _ �®O T _ ype-of Grout C &-* ❑ Irrigation __Approx:.'Depth D.Eastern ;Surface Seal Installed by Repair Work Done ❑ -Type of Pump . H.P, tate Work one 4 WeII Destruction Well Diameter _ Sealing Material [to �{ vie,) Depth mag _ Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -- -- available within 200 feet.) � � fnstallatiori will serve:-Residence " Commercial_ Other r Number of living units: Number of bedrooms t^ i Character of soil to a depth of 3.feet: Water table depth N SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ # Method of Disposal Distance to nearest:_ Well Foundation Property Line ~ LEACHING LINE ❑ No. & Length of lines Total length/size N FILTER BED ❑ Distance to nearest: Well Foundation Property Line i J SEEPAGE PITS ❑ Depth Size 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 lawsand rules and regulations of the San Joaquin Local Health District. , E Home owner or licensed agent's signature certifies the following: "I terrify that in the performance of the work for which this permit is issued, I shall not 1__Z employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature y certifies the followi "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 Calif ia." i .� The applicant ust call for all wired ins !ction C mplete drawing on reverse side. Signed Title: /� � o. , Date: , FOR DEPARTMENT USE ONLY Application Accepted by tr1 // pp Date Area_ _ n �7 Pit or Grout Inspection by ' Date r /'O� �/ r Final Inspection b Date C� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 racy 835-6985 Applicant- Return all copies to: Environmental H Ith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO !, ,� DATE PERMIT'NO. EH 14-261;_ -7 EH 13-20(REV.101e3f �O S �`S 10$ +� 7��r gto