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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES YYEAR 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. if 0 tl Job Address City Lot Size PM Owner's Name r fbwrlanAddress 657 E• v Phone Contractor�� Address T-Li-Bo1—Li—BolAw License No. ?05140 Phone �� M. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE .TYPE OF WELL PROBLEM AREA CON STRUCTION_PVKrdlFICATIONS r ❑ Industrial O Open Bottom ❑ Manteca Dia. of xcavation Dia. of Well Casing ❑ Domesticl Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications P f'1 Public ❑. Other ❑ Delta Depth of Grout Seal Type of Grout _ rox. De th ( stern Surface Seal Installed by I I Irrigation 7� -App p - Repair Work Done ❑ Type of Pump H.P. State Work Done_ F Well Destruction ❑ Well Diameter ! Sealing Material (top 501 Depth - Filler Material i8elow 50') TYPE OF SEPTIC WORK: NEW'INSTALLATION 1.1 REPAIR/ADDITION E I DESTRUCTIONX Mo septic system permitted if public sewer is Ii 3 available within 200 feet.i Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth C SEPTIC TANK ❑ Type/Mfg --I Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ . I hereby certify that] 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. k, (Z5 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 shat employ any pe on_ in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the o o g: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's cbmpensa tion laws o li ia." �! The applic all far al! required inspections. Complete drawing on reverse side. Signed X I� Title: _ Date: u r FOR DEPARTMENT USE ONLY f ' Application Accepted by Date ` 2 Area iE ; Pit or Grout Inspection b D to Final s ction by Dat6 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVEDBY DATE PERMIT N0. I INFO /GASH f Q �Q 4 + EH 13-241REV,1/951 ',3 Som ( �� r�� O �3/O . EH 1429 L -