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APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT —C 1609 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPJRES,I.YEAR FROM DATE ISSUED N 0 b4 (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. 1851 for well pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ( City Lot Size PIM Owner's Name U �,�s,61 'nowl, ygddress Phone 3—C),01 Contractor �A_ L Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Pi TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC-TAN - -- ----- ..—SEWER LINES- -- DISPOSAL FCD. �P . NE FOUNDATION AGRICULTURE WELL OTHER WELL MPS INTENDED USE TYPE OF WELL rte.PROBLEM CONSTRUCTION SPEC IFICATI ❑ Industrial ❑ Open Bottom r s❑ Manteca of Well Excavatio Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Kms.❑ Tracy Type o Specfications ❑ Public :1_ ❑ Other ❑ Delta of Grou I Type of Grout ❑ Irrigation �4pprox.' Dept.. ' em Surface Seal Installed by Repair Work Done ❑ ump t H.P. State Work �- Well Destruction ❑ Well Diameter 4� Sealing Material (top 50'1 O Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑k REPAIR/ADDITION ❑ DESTRUCTION P(No septic system permitted if public sewer is +---- - ailable within 200 feet.) Installation will serve: Residence I Commercial— Other r - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: µ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal T Distance to nearest: Well Foundation Property Line 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance fo 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 Diitrict:- 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 all for all required ins ctions. Complete drawing on reverse side. i Signed?_ -fid _. Title: e "a-.1 _ T w _ Date: /]� 1�,• OR ARTMENT_U_SE QNLY Application Accepted by _ \C Vim` L `' Date ��' Area I ✓� i Pit or Grout Inspection by �- /Date ,I q Final Inspection by ,C Dat Additional Comments: ❑ Stk 466-6781 LJLodi 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.i i e 5) Q EH 14-28