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r APPLICATION FOR PERMIT J SAN JOAO,UIN-LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ` 'Telephone'(209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISMAD , !I. 1 .• (Complete in Triplicate) gin, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in 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. i Job Address i . -f City Lot Size PM Owner's Name !='I C AddressO S/,(jC ` A/Q Phone Contractor_ =t°I Address License No. Phone PUMP INSTALLATION TYPE OF WELL/PUMP: NEW WELL LJ REPLACEMENT ❑ DESTRUCTION LiC1E SYSTEM�REPAIR-�wnm:mw-wow,ti*OTHER ElDISTANCE TO NEAREST: S NK SEWER LINES - - - - ..� DISPOSA `. -- � PROP. LINE FOUNDATION , AGRICULTURE WECL L � THER WELLt ePITS/SUMPS INTENDED USE TYPE OF WELL PROBLE STI CTION SPECIFIC-IONS ❑ Industrial "` �.+ +.Q-Open-Bottom M:� a Dia. ell Excavation L7 Domestic/Private ❑ Gravel Pack 'Tracy Dia. of Well Casing Type of Casing -- Specifications ❑ Public O Othe ❑ Delta Depth of Grout Seal ❑ Irrigation Type of Grout g ,Approx. Depth ❑ Eastern Surfa'c Seal Inst Iled=bV, Repair Work Done ❑ Type of Pump H.P. r4•t Slate Work Done 11 Destruction ❑ Well Diameter Sealing Material (topw50'i ----mow Depth Fillera.MSterial (Below 50'I TYPE OFiSEPTIC-WORK.-,.KNEW INSTALLATION ❑ REPAIRJADDITIONt� ❑ADES�,T�RUCTION (No septic sy�200 mitted if public sewer is Installation will serve: Residence Commerciaggl, Other vailable withet.I Numberof living units: Number of bedroom's Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i ❑ Type/Mfg !E Capacity PKG. TREATMENT PLT. ❑ No. Compartments � +�+ Method of Disposal Distance to nearest:" Well Foundation Property Line LEACHING LINE ❑ No''& Length of lines I - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - SEEPAGE PITS ❑ Depth �`+ Size �+ Number SUMPS p Distanceto nearest Well ,11, -J- Foundation Property Line DISPOSA'L'PO DS 11t 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 District- Home owner or licensed agent's signature certifies the followin em la an g: "I certify that in the performance of the work for which this permit is issued, I shall not ploy y 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 California." The applicant must call for all reired inspections. Complete drawing on reverse side. Signed Title: - _ 2 0 ' Date: FOR DEPARTMENT USE ONLY Application Accepted by 62 Date ` — Area yF Pit or Grout Inspection by Date Final Inspection by r- Date Additional Comments. l(' ] y 3 0 ❑ Stk 466-6781 ❑ Lodi 369- C1Mante 823-7104 ElTracy 835-6385 J Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box' Stk., CA-95201 !3 FEE AMOUNT DUE AMOUNT REMITTED C INFO SH RECEIVED BY DATE PERMIT NO. f AA i EH 13-24(REV.tO EH 14-4