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t 41 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 16011. HAZE.—AGN AVE., STOCKTON, CA SFPVC 'TAIUR Telephone (200) 466-6781._ s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r. %V ` ^ ;. i - (Complete in Triplicate) r ' 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. :..1 ri ttu 1 k}! _r Ir .ori Job Address X �r woe <7 � City RLot Size PM Owner's Name _-� � � A i _ Phone`r-�Cs��' I Contractor T �7�^zcz� l Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES IDIS_�LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE YPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS ❑ Industrial Q Open m ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E l Domestic/Private ❑ Gravel Pack T Type of Casing Specifications ❑ Public ❑ Other t DeltaDepth of Grout Seal Type of Grout ❑ Irrigation �pprox epth ❑ Eastern ce Seal Installed by Repair Work Done ❑ . Type ump; H.P. State Work Done Well Destruction ❑ Well Diameter ' Sealing Material Itop 501 Depth Filler Material (Below NY) ti 71 TYPE OF SEPTIC WORK::- NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.). Installation will serve: Residence_l Commercial_ Other Number f living units: Number of bedrooms Character n to feet: t ater table depth SEPTIC TANK /Mfg Capacity No. Compartments k PKG. TREATM:7t I Method.of Disposal nce to est: Well Founda' Property Line 1 LEACHING LINE ❑ No. & Length of,lines Total Wigth/_size s FILTER BED ❑ Distance to,nearest: We oundation Property_Line SEEPAGE PITS El Depth Size Number SUMPS ❑ Distance Y i Barest: Well Foundation Property Line DISPOSAL PONDS L1 +{ ' 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 signatu rel 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 applicant muusst-call for all re wired inspectio s. Complete drawing on reverse side. Signed X / �E � Title: Date: ; F R DEPARTMENT USE ONLY f Application Accepted Date ~ 7 Area a Pit or sp Grout Inspecti y Date Final ection by Date .i ,: `f Additional Comments: r. a k ❑ Stk 465-6781 ❑ Lodi 369-3621 Manteca 8x3-71 ❑ Tracy 835.6385 Applicant- Retum all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton A , P.O. Box 2008, Stk., CA 95201 J �. . �I✓�ey4.CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'.NO.' + EH 13-24IREV.1/851 a,T>�+ �v ��'7�, '7--�'7'[f EH 1428 v P -