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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 15-S 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. y �l .�y� J CTYPE b Address m�� 11 JOILD� ��/� o/ " ccity p �1��L.Lzot Size � x �� ,PM ner's Name �'`�T �C--��D w—/&&dd sr�'t] d k Phone &,q i ntractor Address License No. Phone OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION D SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION GRICULTURE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLXAREA STRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manof Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trace of Casing Specifications I M Public rfl Other F1 Deltth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastace Seal Installed by Repair Work Done ❑'x Type of Pump State-Work Done Well Destruction ❑ Well Diameter Sealing Mater (top 50'1 Depth, Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION i (No septic system l6ermitted if public sewer is I ailable within 200 feet.) Installation will serve:"Residence= Commercial— Other Number of living units: Number of bedrooms - I ,r. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No."Comparfine t PKG. TREATMENT PLT. D it Method of Disposal Distance to nearest: Well Foundation Property Line # LEACHING LINE 0 No,& Length of lines Total length/size ,-_`. FILTER BED ❑ Distance, to nearest: Well Foundation .Property Line SEEPAGE PITS l I Depth Size Number SUMPS L1 Distance to 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. 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signatur i certifies the following: -;,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�ipust call for all reqtAged inspection. Complete drawing on reverse side. igned Title: (/ E'f/ z«i_J Date: I6/J2 Jr FOR,DEPARTNIEN7 USE ONLY Application Accepted by ' Date (._I Area Pit or Grout Inspection by Date Final Inspect by ` Data F Additional Comments: 11 Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 635-6385 Appiicant - 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 K RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t/N sl � e" 3�' EH 14-29