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' APPLICATION FOR PERMIT *� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA No �,J Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED No (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 scribed. This application s 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. !9"-- 6, C% s Job Address City Lot Size PM Owner's Name 1/ e�&I,j � 56 1 Phone Contractor Address ��,�-J� License No. Phone_ TYPE OF WELL! MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 1 Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications " 1 {'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ! I I Irrigation --Approx. Depth I I Eas rn Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTA ATION Cl REPAIRIADDITION I I DESTRUCTIONX iNo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial_ Other Number of living units: __�__._ Number of bedrooms .7— Character 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 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl 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 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicaril must call f r}aall`l,rra ufiireddiinspections. Complete drawing on reverse side. Signed .11 It Gl/`l�� Title: Date: FO EPARTMd4 I ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Nb Cf-1-5 ()A0 1Ky ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 V Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT.NO. SH + EH13INFO N�7, 241RfV.�ik51 3:—_) r_ EEH 14-2e ` L t'-,