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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,' STOCKTON, CA Telephone (209) ,466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED 1��m_,_�_ ism ripl�ate� l� --�� 1 Application is hereby made to the Sa Joaquin Local Health District f rr a�Permrt to onostruct and/or install the work herein described. This application is made in compliance with San Jo in County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. J, / Job Address r City ",Lot Size PM Or �. Owner's Name / Phone Contractor rens �i icense No.l iZ9 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL'FLD. PROP. LINE e FOUNDATION .AGRICULTURE WELL . OTHER WELL PITS/SUMPS d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack '❑ TracYT ' � Type'of'Casittg Specifications l 1-1 Public l7 Other Ll Delta Depth of Grout Seal Type of Grout 1 1 Irrigation.* --Approx, Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material itop 501 Depth Filler Material (6510 f TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is V I IF available within 200 feet.). Installation will serve: Residence S' Commercial,-- `Other , NOmber of living units: Number of bedrooms_. Character of soil to a depth of 3 feet: g -- - - — - Water table depth k SEPTIC TANK ❑ Type/Mfg t Capacity M, No. Compartments f PKG. TREATMENT PLT. ❑ t t. T _ t` Method of Disposal h Distance to nearest: Well Foundation Property Line { LEACHING LINE ❑ No. ✓3t Length of lines Total length/size o<1 FILTER BED ❑ Distance to nearest;� "Well _Q . Foundation Property Line EPAGE P l I Depth Size 6 Number MPS Ll Distance to nearest: Well Foundation _-..!i"Property Line DISPOSAL PONDS ❑ " r 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 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-. lion laws of California." •� The applicant must call for all requi nspections. Co late drawing on Leverse.side. 4 Signed X Title: Date: k FOR DEPARTMENT USE ONLY �4• *•1 0 Q. Application Accepted by —Dated _-- U A Area L-2:2-149 ffo Pit or Grout Inspection by Date Final Inspection by q Date . x i Additional Comments: Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 - t Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Helton Ave., P.O. Box 2009, Stk., CA 95201 Hazelton k FEE AMOUNT DUE AMOUNT REMITTEE] CK RECEIVED BY DATE r PERMIT NO. INFO �] CASH _-_ _. —_ _ _{I r EN 1324 IREV.t/n 57 / (' -T-SI-5,S s 4 ,�'� $g - -EH 14-28 - - ( -...---