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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 A (Complete in Triplicate) �7 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. O �/ Job Address Lot Size 4�;b e PM Owner's Name 1 _��11�Cx1tu h.i�'. — Address vV - 4 Q Phone t L Contractor Address License No. Phone TYPE OF WELL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERR u ) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._!: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS INTENDED USE EYP OF WELL PROBLEM AREA CONSTRUCTION SSC40 ATIONS ❑ Industrial ❑ Open Botto ❑ Manteca Dia. of WMLI Ey a ation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T e of Casing Specifications ❑ Public ❑ Other 9 Depth of Grout Seal Type of Grout ❑ Irrigation ��- 4pprrtx'6epth ❑ Eastern Su eal Installed by _..� Repair Work l ❑ Type of Pump __ H.P. State Work Done_ ( t Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) (� Installation will serve: Residence_ Commercial— Other 11 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 length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rule,ss-and regulations of the San Joaquin Local Health District. Hoene 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 c .f.e 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- t n �aws of�California." T e app nt7must call or all re fired inspections. Complete drawing a reverse side. Sign X � - Title: Date: �� FO EPARTMENT USE ONLY Application Accepted by � Date..... 7; Area Pit or Grout Inspection by r� Date Final Inspection by Date Additional Comments: /��.� 11uc-WX4ft S 5 oQE' ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED C K Ad RECEIVED BY DATE PERMIT'NO. a EH 13-24(REV.I/x 5} *36 �c_.) ,Q ��q + �(L 3[.2EH 14-28 '