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APPLICATION FOR PERMIT L�611_ 3 1 V% 6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED [� (Complete in Triplicate) �� J 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. J Job Address /6 5• S 7- City L-47 Lot Size ` 5z�r /M! PM Owner's Name *§dol'ts A-PH'P-- Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTION ❑ NSTALLATION..❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE WELL OTHER WELL P S— INTENDED USE TYPE OF WELL PROBLEM AREA TRU FICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of We ation Dia. of Well Casing ❑ Domestic/Private LI Gravel Pack acy Type of Casing _ Specifications " r M Public ❑ Other - . Delta Depth of Grout Seal Type of Grout _ I I irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Do ❑ Type of Pump H.P. State Work Done_ Well Destruction iEI Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION 1.1_,DESTR TION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other rY 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. ❑ 1�\ (Method of Disposal Distance to nearest: _Well' • --Foundation Property Line .LEACHING LINE ❑t No. & Length of lines. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS i I Depth Size Number SUMPS ❑ "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 Di§trict. Home owner or licensed agents 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 cdmpensation 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 f California." L/ J The appli t c it or it required inspections. Complete drawing on reverse side. Signed X Title: 0 w _r�""� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 3'' 2 Area J Pit or Grout Inspecti yL_ Date Final Inspection by Dat Additional Comments: ,4ff,+in L,/--e C/ l ti 0 j s ❑ Stk 466-6781 C Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. x 2 , tk., A 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO +.EH 13.24 01 EV.I/w 5) CA— b EH 14-2e I 55 �"-J'