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w 5 . ; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-1 ON AVE., STOCKTON, CA Telephone (209) 466-6781 J PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) x 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address ZQ 6 a +'' 15 ` 1 City /U` Lot Size pfH g Owner's Name: 6�aOfX I Address Phone c5 Contractor �� dA / Address �� a icense �f�CI d No. Phon S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack__— OTiacy ''Type of Ca.i.i _'_ 9 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ` ❑ Irrigation ___4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 ~Depth Filler.Material (Below 501 Jv TYPE OF SEPTIC WORK: -NEW-INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Comrnercial'= -Other ; y 1. Number of living units: Number of bedrooms.' Character of soil to a depth of 3 feet: = a Water table depth SEPTIC TANK ❑ Type/Mfg Capacity, No. Compartments PKG. TREATMENT PLT- ❑e'/` Method'of Disposal � r Distance to nearest Well Foundation Property Line I LEACHING LINE ❑ 'No. & Length of lines } Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line t l! SEEPAGE PITS ❑ Depth Size Number SUMPS ❑`Distance.to nearest: Well Foundation t .Property Line DISPOSAL PONDS ❑ t1 ? I hereby certify that { have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. [ Home owner or licensed agent's signature certifies the following: "I certify ihat in the performance of the work for which this permit is issued, 1 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 Califdrnia:�. # The applicant mus all for all required inspe ons. omplete drawing on reverse side. ) Signed 217Title: Date: -- aROR-DEPARTMENT USE-ONLY "' '� Application Accepted by , Date c7a / Area Pit or Grout Inspection by ! /Date - Final;Ins pection by pate f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201�orhv� aI- riK�h ku r�,� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT''NO.C4L el C. 01 �++[l4 F� — INFO CASH 01 t>U