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r r s ` 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 I` 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. 4 Job Address Tf ~• S �� -r--kA -- /,6-7 Cr Lot Size P PM t '- 'Owner's Name' i fL' .' . r�- Addressm�f-'a7 c 1� I hone- Contractor 1,,... '��2�(1Lt 11 �� "•_[.��,�„ ! Contractor Add'res C� �7( y 1 �• ."• 7� f- ._, � J ! f I-' Z' ?b Phone L TYPE OF 1NELL�17�UMP: �. NEW WELL-E! WELL REPLACEMENT ❑ (DESTRUCTION ❑ F PUMPJNSTAL'LATION ❑ YSTEM REPAIR ❑ OTHER C f I DISTANCE TO NEAREST: SEPTIC TANK i I SEWE INES-� DISPOSAL,Fl. PROP-LINE, FOUNDATION ICULTURE,W LL n _OTHER WELL r PITS/SS =t jFFrrff r. INTENDED USE TYPE-OF;WEL'L'_,� P M AREA CONSTRUCTION SPECIFIC ^J N J 'F ❑ Industrial EJ Open Bottom " p Manteca Dia. of Well Excavatio 'Di of•Well-Casing- f ❑ Domestic/Private , ❑ Gravel Pack ❑ Tracy Type of Casing $ �. A"z , g peci ications r q Ll Public ``❑ Other 1 ❑ pelta Depth of, ut Se`la'"" � t -.�TYPe of Grout'- ..ffl ❑ irrigation �q rdx Depth ❑ Eastern , "Surf e Seal Installed by Repair Work Done ❑ Ty of Pump - W.P- I f State Wo Done a , Well!Destruction ❑ ell Diam te�� t o I S ali_r Material (top 50') .. Depth Filler Material (Below 501,.- - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR 1ADDITiONPk DESTRUCTION ❑ (No septic system permitted if public sewer W { available within 200 fee t.) Installation will serve: Re idence�CCommercial Other t `ire 1 Number of living units: Numbe oEf b`dr)ooms y. Character of soil to a depth of 3 feet: -=�- e s Water SEPTIC TANK ❑ Type/Mf t' ` 9 table depth } Gapaciry No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well r " Foundation R Property Line i LEACHING LINE No.'& Length of lines Total length/size .�� FILTER BED ❑ Distance to nearest: Well ��! .Foundation y� � Property Line �-- `l r r ' I a: SEEPAGE PITS ❑ Depth Size Number i SUMPS Distance tonearest: Well - Foundation H_property_Line c 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, stale flaws, 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 Callfomia."Cont actor's hiring or.sub-contracting signature certifies the fall ing: "I certify that in the performance of the work for which this permit is issued„I shall employ persons subject to workman's compensa- of C f tion laws nia.” d � r i The applican aRfor all jecluired or pections. Complete drawing on reverse std J Signed X Title: Date, s a FOR DEPARTMENT USE ONLY Applicatio?_A'mCept;d bey 1�i � { f h�) _ Date �'� Area_ Pit or Grout Inspection by lv Date Final Inspection by Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 623.7104 ❑ Tracy 835-6385 F Applicant- Return~all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk-, CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH t + EH 13-24(REV.1/H 5) _70 % _F EH 14-29 O % 0:c, Kot i