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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Joh Address S -5 a� e �} City / ti' /'p Loi Size C+�'a PM Owner's Nametl 13��Q 1"�I .J _rnJ4/✓l '-k-,,Kddress � ��.11' k 14 Phone Conr trac or f t5- `/ ress - / /� �/� / fir' License No.7 DyV 6 ` Phone 2Z TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 pluy' INSTALLATION ❑ 9 L SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE_ EST: SEPTIC TANK %iSEWER.LINES_--,DISPOSAL FLD. PROP. LINE FOUNDA710N _.. AGRICULTURE WELL ftA OTHER WELL Pi LIMPS INTENDED USE OF WELL PROBLEM AREA"'CONSTRUCTION`SPECIFI ❑'Industrial CI Bo O Mnteca Dia sof Well ion Dia. of Well Casing ❑ Domestic Private ❑ Gravel Pack Tracy o Casing ` ' Specifications ❑ Public ❑;Other ❑ Delt Dep h of4Grou-t Seat ' Type of Grout w �� ❑ irrigation �pprox. Dep Eastern "'�� ace Seal installed_ by Repair Work Done ❑ Type of `H.P.' "'" State Work Done Well Destruction ❑ Diameter Sealing Material (top 50'1 Depth . Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ©��REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is available within 200 feet.► ' Installation will serve:' ResideCce Commercial_ Other Number of living units: of bedrooms { Character of soil to a depth oWater table depth 14 SEPTIC TANK ❑ 'T apacity No. Compartments s� PKG. TREATMENT PLT. ❑ Method of Disposal Dea est: Well undation Property Line LEACHING LINE ❑ No. & Length of lines tal length/size FILTER BED ❑ Distance to nearest: Well!vv Foundation i la Property Line SEEPAGE PITS ❑ •Depth Size NumhAr r22 t 'N >,�J t y r SUMPS 171 Distance to near t: Well 26D Foundation ,1F66pertyy U e yo .r= 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: "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 must call for all requited inspections. Complete drawing on reverse side.. f Signed Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date Area_Q } _ it or rout Inspection by Date � � Final Inspection € t . Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Yracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT NO. + E"13-24 IREV.1 EH 1426 / 1