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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 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. ��+� �i Job Address �K D� /tea- eve Aicle-, - - -- City 147Lot Size PM Owner's NameC-4Address ZS Phone '3 Contractor�� _ Address 5� License No. Phone G 33 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES�TIC , SEWEfi"LINES- s t" " " ` DISPOSAL FLD. PROP. LINE +AGRICULTURE WELL OTHER WELL MPS INTENDED USE TYPE OF WELL OBLEM AREA C SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy of Casing Specifications 4 (� Public Cl r ❑ Delta Depth of eaI w Type of Grout _ I I Irrigation _..Approx.,Depth I 1 Eastern Surface Seal Installed _ g _ i Repair Work Done 0 T e of Pum H.P. State Work on _ P yr P Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth ) Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence 4� Commercial_ Other Number of living units: Number of bedroolrfs Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ e Method of Disposal Distance tonearest: Well Foundation Property Line � 1 LEACHING LINE ❑ No. & Length of fines Total length/size a � FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I P 'De th Size Number �Ilr R I SUMPS El 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 Di?;trict. 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 must call fcw a regu' t10 . Complete drawing on r arse side. — 47- ,-6, Signed X Title:)_Y �s�C,�� '-I Date: ..G � FOR DEPARTMENT USE ONLY '7 plica ' n Accepted by Date `� o Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: y7C. 4 4s D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,A Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 11! FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"No. ! r. # )SO EH 13-211REV.tH57 c EH 14-28 '