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APPLICATION'FOR'PERMIT Lb SAN JOAQUIN LOCAL HEALTH DISTRICT JUN P; 1601 E. HAZELTON AVE., STOCKTON, CA ;AN JOAQUN ®��t Telephone (209) 466-6781 HEALTH QICTRj��' 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. i • Job Address g,J LA W �110 City LC> Lot Size PM Owner's Name Address r 1 Phone Iell -a2pZ� 7 Contractor's Name, �-- N License No. c& 10 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 9 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK s SEWER LINES - DISPOSAL FLO. PROP. LINE r ' F,QUNDATION r AGRICULTURE WELL i- � i`OTHER WELL' ` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r Type of Casing Specifications �f Domestic/Private E] Gravel Pack' ❑ Tracy p 9 ❑ Public C1 Other ElDelta < Depth of Grout Seal Type of Grout ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 10 Type of Pump L1 - H.P. h "'"x� State Work Done u Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo-septic system permitted.if.public sewer is available within;200 feet.) Installation will serve: Residence Commercial_i Other Y._-Number.of.livin9 units:_—__Number of bedrooms Character of soil to a,depth of 3 feet:: Water table depth SEPTIC TANKS s �" Ty j Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line • i ( LEACHING LINE ❑ No. & Length of lines ' ' Total length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line. SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I I hereby certify that I have prepared this application and that the work will be 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 subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 4 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." The applic t ust it for all eq 11ir2 spections. Compiete drawing on reverse side. c�{ Signed Title: ' Date: /.�^ o l FOR DEPARTMENT USE ONLY {{ Date b ZZ 4 Application Accepted by�— - Area - ✓� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE F AMOUNT REMITTED CASH RECEIVED BY /DATE PERMIT'NO. + EH1&24IAEV.t0l8315 J Qb�1 � r �/ Y��gl M �4�� EH 14-26