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L7S APPLICATION.FOR PERMIT SAN JOAQUIN"'LOCAL HEALTH DISTRICT No WV_L��Ut`` y 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) p Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei described. This a"ppli`ca�ti'on 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. Hi L� w CSG I Job Address T� , C�t�_ ` of Size PM Owner's Name al� �`Q`�14ddte r `� Phone a-�,� Contract Address�_� �_� License No. Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM AIA ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ALEREAONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ype of Casing Specifications ❑-Public ❑ Other epth of Grout Seal rType of Grout ❑ Irrigation Approx. Depth urface Seal Installed by (�Repair Work Done ❑ Type of Pump State Work DoneWell Destruction ❑ Well Diameter Sealing_M_RA. (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is j I available within-200 feet.) Installation will serve: Residence_ nCommercial Other € _ ` Q r Number of living units: Number"of bedrooms Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �V PKG. TREATMENT PLT. ❑ 0� Method of Disposal Distance to nearest: Well Foundation .Property Line c LEACHING LINE" ❑ No. & Length of lines -� Total length/size FILTER .BED ❑ Distance to nearest: Well Foundation` a Property Line SEEPAGE PITS ❑ Depth Size — Number " SUMPS ❑ Distance to nearest: -t Well Foundation Property Line t" 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 appli _ t call for all re fired inspecti Complete drawing on reverse side. C ! Z Signed XTitle: Date: FO DEPARTMENT USE ONLY Application Accepted by Date �Ar 4A1aa 49 r Pit or Grout Inspection by Date Final Inspection byF Dater Additional Comments: 77 4 ❑ Silk 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 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. INFO CASH + EH13.24(R E H 14-28 EV,t/n 5)