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APPLICATION FOR PERMIT h.. - SAN .IOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 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 !PMI ,' City 4Anw Lot Size 154 ) A Sa PM Owner's Name 20"P 'Z2- � 4060 Address /�/�T�.ri !L! 5�t Phone S / i Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK,.,- SEWER ES DISPOSAL FLO. PROP. LINE FOUNDATION AGR LTU WELL OTHER WELT PITS/SUMPS ' INTENDED USE TYPE OF WELL P B AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ an a Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications 71 Public Cl Other f1 Delta pth of Grout Seal Type of Grout i l Irrigation ''_ � A y ox. _- — g pp pth - l I Eastern Surfa eel Installed by Repair Work Done L1 Type of Pu p H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION I I DESTRUCTION l (No septic system permitted if public sewer is available within 200 feet.) (1 Installation will serve: Residence_ Comrrierci@-'""°"" Other tJ ' Number of living units: Number of bedrooms Character of soil to ;.depth of 3 feel: Water table depth 11" SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0-0. Method of.Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ N•o. & Length of lines Total length/size f� FILTER BED El Distance to nearest: Well Foundation Property Line C 4. SEEPAGE PITS I I Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line .t 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 Sart Joaquin Local Health District. f 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 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 Calif nia." The appfican t call II req 1r rns tions. Complete drawing on reverse side. Signed Title: Date: I IJL(LFOR DEPARTMENT USE ONLY Application Accepted bydhfi Date Area _ Pit or Grout Inspection by Date Final Inspection by Date f _ ff 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 FEE INFO AMOUNT�DU7E^�� AMOUNT REMITTED CK# RECEIVED BY DATE /PEERRMIT'NO. + EH 13-241F1EV.1/95Y �5• (.Jv C� �� EH 14-28 .! �3