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,, APPLICATION FOR PERMIT ' { s , r SAN JOAQUIN LOCAL HEALTH DISTRICT � ` 1601 E. HAZEL i ON AVE., STOCKTON, CA / Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M (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' Job Address 2028 Qhtwad City Lot Sizeln�_Igo ---- PM r } X Owner's Name H len HatAieLL_ Address 9029 01imad Phone 464-99851 48ZU Ram CaMt) ;tiiA&ress 3245 WateAtoo Rd. License No. 341375 Phone 9 Contractor a TYPE OF WELL/PUMP: ',NEW WELL ❑ WELL REPLACEMENT ❑ <1..1`.DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ DISTANCE TO NEAR T: SEPTIC TANK SEWER ONES — DISPOSACFLD.""r" PROP, LINE NDATION AGRICULTURE W OTHER WELL'S-._ PITS/SUMPS INTENDED USE TYPE O LL PROBLEM ARE ONSTRUCT_ION SPECIFICATIONS, ❑ Industrial ❑ Open Bottom LlMan ► Dia. of Well Excavation Dia. df Well Casing L1 Domestic/Private ❑ Gravel Pack cy I Type of Casing Speci,cations D; F1 1 Public f 1 Other Delta t Depth of Grout Seal + Type of Grout I I Irrigation Appr Depth l I Eastern urlace Seal Installed by f I Repair Work Done ❑ Tv. r Pump HIP. i State Work Done ^ I Well Destruction EI ell Diameter Sealing Material stop 50'1 ' Depth Filler Material (Below-50'6 S t - TYPE OF SEPTIC WORK: NEW INSTALLATI REPAIRIADDITION l I DESTRUCTION' (No septic system permitted if public sewer is i f vailable within 200 feet.) Installation will serve: Residence Commerc Other Number of living units: Number of bedro p, i Character of soil to a depth of 3 feet: � Water table depth Mfg No. Coh ' SEPTIC TANK ❑ Type/ Capacity # mpartments PKG. TREATMENT PLT. ❑ �. Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines t ,Total length/,size #� r. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE1fIFS _I' ,` ''l�>I oept � Size "� iZ 3N m6ar " SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL- PONDS ❑ Ihereby 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 ai 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 applicant st call f required inspections. Complete drawing on reverse side. `Signed f Title: Date: t {/ /�I�.!/{ FOR DEPARTMENT USE ONLY Application Accepted by `�I '.� Date '23 Area / Pit or Grout inspection by Date Final Inspection by Date �I I Additional Comments: r^ – ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEEAMOUNT DUE AMOUNT REMITTED O RECEIVED By DATE PERMIT NO. INFO l ♦ EH 1344 IREV.i/N 51 � EH 14-29