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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 (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 i 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 �- -• f -3 I V "-7 City• Lot Size PM _MAi Owner's Name _. � Address 5, Phone F,6�Ix Contractor C Cfl~ S'I Address P40146 License No. 99�0Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT INTENDED USE TYPE OF WELL �~ PROBLEM AREA CONSTRUCTION SPECIE ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. cavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Trac �' Type of Casing Specifications ❑ Public ❑ Other elta, Depth of Grout Seal Type of Grout ❑ Irrigation Depth ❑ Eastern Surface Seal Installed by "µ Repair Work Done ype of Pump I H.P. State Work Done Well Destruction' ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 h TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is V} available within 200 feet.) V Installation will serve: Residence_ Commercial— Other .4 Number of living units: Number of bedrooms Charactertof soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LIN_ E O No. & Length of lines Total length/size FILTER BED .. a ❑ Distance to nearest: Well Foundation Property Line s SEEPAGE PITS �` i❑ Depth —Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I 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 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 call for all requireins tions. Complete drawing on reverse si - / p Signed 'L''`— Title: Ll 49,A Date: FOR DEPARTMENT USE ONLY 3 Application Accepted by Date " Area _ Pit or Grout Inspection b Date Final Inspection by �, � Date Additional Comments: .S L c� G z°?- ?7 7rJ `tom ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca 823-7104 tTracy 835-6385 kita4teiG t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200 Stk., CA 952 1an y xAAu/ ds FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. INFO P�s1_-,g �� / _�SS + EH 1324(REV.t i a 51 _ EH 14-26 7 i "'i, J (j 7—1� ! f !i