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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) y 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. f i Job Address 4 0y S4-El A.P CJ ()L � City C0101 Lot Size ! C PM Owner's Name F 1.(1 M--r � � C,. _ Phone S L]" Contractor's NameQHS a( �}f)@ License No. 4- 3 S L3 Q Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ T �SYSTEM_REPAIRF❑, -OTHER ❑•�� '�` " —DISTANCE TO NEAREST: SEPTIC-TANK''T "^� §EWER LINES DISPO FLD.; PROP. LINE FOUNDAT6N AGRICULTURE WELL ER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA _ CONSTRUCTI _ SPECIFICATIONS. i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of W Excavation Dia. of Well Casing + ❑ Domestic/Private ❑.GraGel Pack >Delta h�of�Casing Specifications ❑ Public ❑ Other ! Depth'of.Grout Seal Type of Grout ❑ Irrigation,, ---Approx. Depth Surface Sealfn Iled byRepair WorkDone ❑ Type of Pump . State Work Done V Well Destruction '❑ Well Diameter# Sealing Material (top 50') Depth Filler Material IBelow 50'a Q� ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Res ante Commercial'_ Other Number of living units:, Number of bedrooms Character of soil to a depth of 3 feet: j P T �---� Water table depth SEPTIC TANK ❑ Type/Mfg ' — -- C= C�, Capacity6 No. Compartments PKG. TREATMENT.PLy. ❑ L- Method of Disposal + Disfance to nearest: Well/__QQ�L}Foundati _ Property Line�_ {� � ?O LEACHING LINE �( r g Total length/size J No. & Len th of lines 7 r ;� 1 _ FILTER BED ❑ bistance to nearest: Well Foundation °f' Property Line-,�17 #• Vie_. SEEPAGE PITS ❑ Depth L� Size - Number;"' . SUMPS if Distanceto`nearest: Foundation O � Property-Line�'�(� DISPOSAL PONDS ❑ I hereby certify that 1-have-prepared-this-application-and-that tK6 workwill be done in accordance.-wijh San JBaquin 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�wliich 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 i 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 applica ust call for all required inspections. Complete drawing on reverse side. •. Signed Title: Date: JI FOR DEPARTMENT,USE ONLY t� 7 Application Accepted by Date Q Area- ;7 �2 47 Pit or Grout Inspection by Date Final Inspection by J Date�G� Additional Comments: ,r ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 8,23-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmntal Health Permit/Services 1601 'E.•Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVEQ BY INFO - q DATE p PPEERMIT`NO. ..__CASH.-- +EH 13-24 IREV.10!931 1 I f r EH 14-26 1.J