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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 (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 District. L� �/��,, ,,_ Job Address T City 1 Lot Size� PSN r Owner's Name � dress C-7-r7-A. Phone J_Jf t Contract; e. dress �7 N LE,4 License NOY- iz' " Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 -6 FT PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ J DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ race Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ra Type of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Dept 1 I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I KREPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is r r/ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 90 �/C �, / Number of living units: _ Number of bedrooms (�IV�" V^ J 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 v Distance to nearest: Well_/_5� Foundation�Z!!L Property Line 1�1^_3/cwt LEACHING LINE Cl No. 8 Length of lines 3 Total length/size S /1 FILTER BED ❑ Distance to nearest: Well /L7 d Foundation Property Line Cl 1111 SEEPAGE PITS I I Depth Size ' ^Number _ SUMPS ll Distance to nearest: Well/0-0 Foundation.CYO Property Line J DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a 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-Q tion laws of California." The applicant ust call for al required inspections. Complete drawing on reverse side. O Signed X Title: DL-r-4..�-✓L e Date: - FOR IDEPARTMENT USE ONLY ��} ��f��` ��-��, ...�� CCC�� Ap cation Accepted by n Cv Bbl � Dated Area + 6f-Ipt Grout Inspection by `4 , Date lo'" Final Inspection by w 1A1-K� � Date r b-ay'�Z/11 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635.6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �e IFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ) DATE PE�Rtf�MIT Nry0EM ).� • Ix-24 IREV.1/e51 EH