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E r APPLICATION FOR PERMIT C) USAN JOAQUIN LOCAL HEALTH DISTRIC?f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) OFly Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. Job Address _144 I? S �`� ' t✓:� City '/W r Lot SizePM Owner's Name ct�lfl� Address f� (7 ) J CCi/'V✓! �,�'7,- Phone 0 f [ 2-1 Contractor Address ---eC WC �j'G- L7. icense No. �C Phone TYPE OF WELL/PUMP: NEW WEI' WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P OBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavati n Dia. of Well Casin ).Qomestic/Private ravel Pack ❑ Tracy Type of Casing r Specifications [I Public ❑ Other ❑ Delta Depth of Grout Seal ��! Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water'table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. 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 m a or all r ire° ms ctions. Complete drawing on rever e. ti Signed XTitle: Date: r� FWDEPARTENTE ONLYApplication Accepted by Date � Area © 6 Pit or Grout Inspecti n by Datenspection by ' !/ Date �Jj r� Additional CammeAt vv u ; ❑ Stk 466-6781 El Lodi -3621 ❑ Manteca 823-7104 ❑Tra M5-6385 oxApplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Stk., 9 wi, v 50� 5201 r vvv INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. 9 + EH 13-24 MEV. /a5) EH 14-26