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r APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e5-., (Complete in Triplicate) y 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 Sari Joaquin Local Health District. . - ., i t /t��.�.fn1 { �l j -� /I Job Address � � �� Lo't Size PM t�f P�+ Phone .) Owner's Name . 1 L 4)Ill):�E�'- Address Contractor's Name a i4ill License No.' 1 Phone TYPE OF WELL/PUMP: NEW WELL t WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E3 ' SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK 6 f- SEWER LINES' ' DISPOSAL FLD.�PROP. LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S I i d ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava'on Dia, of Well Casing Domestic/Private Gravel Pack- XTracy Type of Casing Specifications ' ❑ Public ❑ Other ❑ Delta - Depth of Grout Seal Type of Gro__. ro ! ��yj � f ❑ Irrigation 4�Approx. Depth ❑ Eastern Surface Seal Installed by a«a�I u— - El Work Dane ❑ Type of Pump I H.P. S I 119 Well Destruction ❑ Q,Well Diameter Sealing Material Itop 50'1 Ao � Dept Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system.permitted if public sewer is available within 200 feet.) F Installation will serve: Residence_ commercial_ Other 's Ul Number of living units: ` Number of bedrooms `� f Character of soil to a depth of,3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg..I Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� 1 1. Method of Disposal Distance to nearest: Well 'Foundation Property Line ! LEACHING LINE ❑ No.'&"Leng h of lines ; _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i o SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ; t F 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 N rules and regulations of the San Joaquin Local Health District. �\, k 1 0 tify Home owner or licensed agent's signature certifies the following: "I certhat 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 call fo II r ued inrs1pections. Complete drawing on rev, Title: side. �.—.. " -Date: L FOR DEPARTMENT USE ONLY Am / = S rl� ! Applicatio ccepted by Date �. Pito 5-o spection by Data –?FFinal Inspection by T Date Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 . i 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 CASH RECEIVED BY `DATE PERMIT"NO. INFO !! +EH 13-24(REV.101831P ��l Clv EH 14-26 " 3'