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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.TON 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 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. �Q Q i Job Address 29— 6 5'r K w,�`{i City S 7- -'' �Lot Size ! PM Owner's Name 0 W 5W 6_U41 Address 574 O�k'5110- .CT- Phone �7 4)3 Y Contractor_ '`��y Address �' 57-9W AY' 5ri—License N1-q2'362 PhoneT'7�2 "r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUM ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION RICULTURE WELL OTHER WEL MPS !�- INTENDED USE TYPE OF WELL PROBLEM AREA N SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Mantec Dia- of xcavation Dia. of Well Casing t-- © Domestic/Private ❑ Gravel Pack - racy Type of Casing Specifications 1-1 Public"L' 1 Other f.1 Delta Depth of Grout Seal Type of Grout I i Irrigation - pprox. Depth 13 Eastern Surface Seal Installed by _ Repair Work Done ype of Pump H.P. State Work Done Well Destructi. 11 Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTIONINo,septic system permitted if public sewer is ' - available within 200 feet.) Installation will serve: Residence Commercial— Other E Number of living units: Number of bedrooms . x Character of soil to a depth of 3 feet: t ¢ Water table depth SEPTIC TANK 4�Type/Mfg Capacity 0 No. Compartments } PKG. TREATMENT PLT. ❑ � - _ _ _ Method of Disposal Distance to nearest: Well Foundation Property Line 1, j r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line n SEEPAGE PITS I 1 Depth Size Number `r SUMPS ----^ - L1 -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. i 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 al r all quired inspections. Complete drawing on reverse side. -A�f 1 Signed Title: , r`A ©wr�/E� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �- Area //' Pit or Grout Inspection Data Final Inspection b Date , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMWND. ) a EH2e V 13-21(REV.1/K 51 2 EH 11-