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r 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 ' w x - >na►" � - ' (Complete in Triplicate) i 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: -%;inti, r1T1 - Job Address City OG Lot Size 1) PM K -d Owner's Name Address J o �/ �? Phone " Contractor kddiess r License NoAN. Phone : TYPE OF WELL/PUMP: jVEW WELL C-.. C WELL REPLACEMENT ❑ A DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ "OTHER ❑ DISTANCE TO NEAREST: @T-AN SEWER LINES DISPOSAL FLD �-PP. LINE FOUNDATION AGRICULTURE WELL OT ELL /SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONST N SPECIFICATIONS 9 . + t ❑ Industrial !❑ Open Bottom ❑ Manteca ia. 6141 ell Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ y Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation l rox. Depth ❑ Eastern Surface Seal Installed by Repair Work Do Type of Pump H.P. State Work Done i ` Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth `A Filler Material (Below 501 z {� TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ,{No septic system permitted if public sewer is A }U, I available within 200 feet.) ; G Installation will serve: Residence J Commercial— Other Number of living units.f Number of bedrooms Character of soil to a depth of 3 feet:] Water table depth SEPTIC TANK ❑ Type/Mf61 Capacity No. Compartments ,. .4PKG. TREATMENT PLT. ❑ Method of Disposal., ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I w FILTER BEDS 17Distance to nearest: Well Foundation Property Line FSEEPAGE PITS ❑ Depth Size Number " ; SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS CJ t 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county0or'dinances,estate 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 rued, I shall not employ any person in such manner as to lbecome 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." ..i l j ,T,he applicant must call for all required inspections. Complete drawing on reverse side. SignedTitle: P ' ;Date: FOR DEPARTMENT USE ONLY, t a ,�- ,. .w. -...:�. --- L — .. Y r .. .a. ... r Application Accepted by T Date >`� j Area Pit or Grout Inspection y. Date Final Inspection by 7 f, Additional Comments: .I] Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca j 823-7 ❑ Tracy 83&6385 Applicant- Return all copies to: Environmernal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT-DUE AMOUNT REMITTED t INFO +CASH RIECEIVED BY DATE PERMIT'NO. . + EH 13'24{REV.1/B 5) t? Y J ��— EH 14-28