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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE-LTON 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 sewag or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 0 X--A �[3 , Job Address O 0� lii City Lot Size•"�� t PM Owner's Name t o AlheA r- 'A3fdress 90Vhone Contractor Address 5• License No. 3l A Phone ` 6 TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ r, PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'l INTENDED USE TYPE OF WELLPROBL AREA CONSTRUCTION SPECIFI I ( � 7 EIIndust' ❑ Open ottom anteca Dia. of Well Excav tion Dia. of Well Casing amestic/Private ravel Pack ❑ Tracy Type of Casing Specifications mfil&/Z ❑ Public ElOther ElDelta Depth of Grout Seal Tye of Grout ❑ Irrigation ---Approx. Depth "Eastern ce stalled by A Repair Work Done ❑ Type of Pump _ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 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.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 thatin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tionlaws of Ca'o is"' The applican t quired inspections. Complete drawing on rose side. Signed Title: Date: EPARTM ENT USE ONLY Application Accepted by ��( � �4.tre�l0. Date 61 ea Pit or Grout Inspection bDa/te �+/ Final Ins ti by Date Additional Comments: ev, &�I/e /wz ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 Tracy 8354W5 ;* Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE P M T ` l�7 9 + EH 13-24 WEV.1/65) - .(11 EH 14-26 �`