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{� APPLICATION FOR PERMIT NO W SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA N 2i L� v1 1,-Irz� Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED \1 , 1 {Complete in,Triplicate} N�.�Q: �� ''z Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein tlascribed.This application is I 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. * { + e^ f"3 0i L Job Address Q C +�/Zr� ✓6 = / •+ :'l!' ":� ... J City ��s �C�bIVLot Size PM IT f f Owner's Name d`� ,1.U(S-C Z -- Address D S. �1Z 6 ,� ItC _ Phone - S�6 S` Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC K SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AR C UCTiON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing 4 ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casin Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type'of Grout - ❑ Irrigation —_.Appr epth ❑ Eastern Surface Seal Installed by �'% Repair Work done ❑ Typ Pump H.P. State Work pone Well Destruction ❑ ell DiameterScaling Material Stop 50') w Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONiNo septic system permitted if.public sewer is 4. available within 2 Installation will serve: Residence_+ Commercial_ Other r— /4 Number of living units: Num II r of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Distance to Method of Disposal nearest: Well Foundation Property Line w' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to:nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number d SUMPS, ❑. Distance toi 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. w 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- tion laws of California." The ant must call for all required inspections. Complete drawing on reverse side. Signed Title: bate: FOR DEPARTMENT USE ONLY r Application Accepted by q,�,,� •s �...�/. Date Area } Pit or Grout Inspection by Date Final Inspection by Date� 2 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Ma ca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T� FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PER r' INFO �r^�— / MIT NO. w + EH 14281REV.1i95)- .��,U� 7 Fj��o 35..._ .��\ �I �^-F '