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_ APPLICATION FOR PERMIT ss SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 r (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. 4; Job Address Lot Size s _ PM Owner's Name ddress �' Phone Contractorft7� Address��b �-'$ License No. �0ZZ4�Phone TYPE OF WELL/PUMP: .,� NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP IN ALLATION ❑ SYSTEM REPAIR ❑ f OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES, DISPOSAL FLD. PROP. LINE FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CTlON SPECIFICATIONS Q Industrial LJ Open Bottom Ma Dia. of Well Excavation # Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing Specifications fl Public Cl Ot Cl Delt Depth of Grout Sea! Type of Grout I 1 Irrigation _..Approx. Depth I I Eastern Surface Seal Installed byV Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing rial Itop 50') t Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i.1 DESTRUCTION (No septic system permitted if public sewer is T211 vailable 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 �J } SEPTIC TANK ❑ "Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ `"t ti J ��t , +; L Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ° ❑ Distance to nearest: Well Foundation Property Line >� SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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: "1 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- tion laws of California." The applicast call for all re 'ed in ction Complete awing on reverse side. Signed X f� Title: —_L/cr�'`�/ `r Date: _ .FOR DEPARTMENT USE ONLY Application Accepted b Date Area Y Pit or Grout Ins by to Final Inspection by Date /) ZS I Additional Comments: v +D S '"`�S YJ 6 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365cti. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,,O. Box 2009, Stk., CA 95201FEE INFO AMOUNT yDUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMI-r NO. + EH 13-241REV.t/x57 � 4� EH 1429 /" _o / !f2