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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Nb u) I 1601 E. HAZELTON AVE.,::STOCKTON, CA Telephone (209) 466-6781 SV plo j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,; � y r r wY (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. { Job Address rCJty lG Lot Size PM .. Owner's Name L( L";-ddress' �' Phone Contractor k t + 's; ddress f L L �c c. License Na.� Phone TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCT,ION ❑ ,A UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1DISTANCE TO NEAREST: SEP NK SEWER LINES _ 1 f DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL THERAWELL PITS/SUMPS INTENDED USE TYPE OFWELL'-" PROBL TRUCTION SPECIFICATIONS z ❑ Industrial ❑ Open Bottom ❑ Mant Dia. ell Excavation Dia. of Well Casing { � ❑ Domestic/Private ❑ Gravel Pack racy Type of CasmVJ ❑ Public — Specifications ❑ Other ❑ Delta Depth of Grout Se _' T ❑ Irrigation Type of Grout 9 rox. Depth ❑ Eastern Surface Seal Installed by r ; Repair Work Done ❑ ype of Pump H.P. State Work Done P' ' Well Destruct- ❑ Well Diameter Sealing Material (top 50') f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No,septic system permitted if public sewer is �,'—...__� -----+-y ` `" - available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r S } Method of Disposal ..._. Distance to nearest: Well Foundation r Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ri'1 ❑ Distance to nearest:- 4 Well Foundation Property Line 4 I j , SEEPAGE PITS ❑ Depth - -size f Number SUMPS ❑ Distance to nearest: Well Foundation -- :Property Line DISPOSAL PONDS ❑ `- I hereby certify that I have prepared this application and that the work wilt-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 compansation.laws of California.K'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." v The a plicant m call all req "ed inspe o . Co late drawing on reverse side. I Signed X Title: Date: (1 A�80TMENT USE ONLY Application Accepted by P�'1`�A1, M, -�� Date 3—a, �� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 46&6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 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 CK RECEIVED ilY INFO �7 DATE PERMIT NO. EH 13-24IREV.tig51 �1s'CJ-� -UJ - - r� �y.t EH 14-28 4 1 1 f I I