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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 DistricyA. Job Address City Lot Size PM Owner's Name � � 5Weg0:!Address r�/ � a 'l i /r Phone 334' KR r t y Contractor' Address 4R/ Llcense`iVb. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION, PUMP INSTALLATION ❑ SYSTEM REPAIR i'fl 'OTHER DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES t DISPA,ArL,FLD.= PROP. LINE { FOUNDATION AGRICULTURE WELL OTHEA'W�' El`N� ' f PITSISUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONS TRut-TION SPECIFICATIONS ❑ Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation S ;,Dia. Df well Casing f ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing E J-- pec ifications M Public Other Cl Delta Depth of Grout Seal l Type of Grout _ I I Irrigation .-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done; L-1Type of Pump 4-r H.P. y,` State 1W6rk Dome Well Destruction Well Diameter _�._._—. .__4►'. Sealing Material Itop '!r 10 Depth n Filler Material (Below.b9') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l I DESTRUCTION.4L!(No septic,system permitted if public sewer is available %kithin 200 feet.) Installation will serve: Residence Commercials_ Other E Number of living'units: Number of bedrooms Character of soil'to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfgf] Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WeEI" _Foundation"""'r'"1Property Line LEACHING LINE ' ❑ No. & Length of lines Total length/size FILTER BED f ❑ Distance'to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size _ Number SUMPS ❑ Distances 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. 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 applican s equire �Compleleing on reverse d� Signed X l�: Date: { IF FOR DEPARTMENT USE ONL Application Accepted by �LSZ Date --Z� Area Pit or Grout Inspection by Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Aanteca 823-7104 ❑ Tracy 835-6385 Applicant - Returnall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 „ FEE CK 9 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT'NO. a EH13-24(REV.11K51 EH 14-26 U 1 1 _` i