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F1APPLICATION 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. f the 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 A5 -20 1 ,` r/'-{f N Jk \r _ � — City ize PM G L 8 j Address `� Phone Owner's Name r1 �^ Contractor 6Fi Address dx License No:�BiD%x 7 Phone I I T PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -----.:.-.PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0.+1 INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of W vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout C1 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 5(Y) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION EFWESTRUCTION ❑ (No septic system permitted if public sewer is (7 available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:-G---- Number of bedrooms Character of soil to a depth of 3 feet: _ f TTygzp, `-i- S/ Water table depth I SEPTIC TANK Ed,'-Type/Mfg C capacity arl% No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �1LEACHING LINE 01�-No. & Length of lines �� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PETS �_ Depth _�-5 Size 3 3 - Number SUMPS 0 Distance to nearest: Well Foundation �� Property Line S r DISPOSAL PONDS ❑ L 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 fff � 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 j-^ c ifies the following:"I fy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- S tion of California." The applican st call fojli tion . o lete dra ng on re rse side. Sign _ me: , Date: "~ FOR DEPARTMENT USE ONLY 67r tion Accepted Date ��`� � Area dr0 Final In Daterout inspecti y Date Inspection by Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT`NO. INFO I t l + EH 13-24 IREV.1/a 5) �`- �"'7�` p - `/x,7 EH 1428