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F APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (Complete in Triplicate) Application is he,eby made to the Sari 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 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. �, ,2 f .J f v�� y � Job Address �!'1/it, Cit Lot Size PM �Q/ 'l. Address F Phone Owner's Name �xb// Flu c,✓v� Cgntraciar�4 Address =- Cc� H' License No,.3/9� Phone TYPE OF WELL/PUMP: NEW WELL 171WELL REPLACEMENT El _ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WE70_�!_a PROB LEM RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom of Well Excavation Dia. of Well Casing ❑ Domestic/Private L-1 Gravel Pack e of Casing Specifications PublicAtherDepth of Grout Seal Type of Grout I I Irrigation _--Approx. DSurface Seal installed by Repair Work Done ❑ Type of PumpState Work Done Well Destruction ❑ Well Diameter ng Material Stop 501 III Depth Filler Material (Below-50')... TYPE OF SEPTIC WORK: NEW INSTALLATION {'l REPAIR/ADDITION E I DESTRUCTION A availseptic systemithin feet.)miitted if public sewer is 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthisize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS Ll Distance to 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 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 p on I uch manner as to become subject orkman's compensation laws of California." Contractors hiring or sub-contracting signature certifies th olio 7- 'I certify that in the performance f e work for which this permit is issued,I shall employ persons subject to workfman's compensa tion Gaafor a.' The ust all or all require ctio plate drawing on rave e sr e. w Sign Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b Date II 3—,P.7-- Area F. Pit or Grout Inspection by Date Final Inspection by �`— Date Additional Comments: G O d,—; 1-a S ❑ Stk 466-6781 ' © Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo>c�2009, Stk., CA 95201 UT FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. }Ss�f10 INFO rrT rt� + EH 1324 iREV.I/H 5) �� `� 13 2� p EH 14-28