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s • APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �' c 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209). 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - v I', w,; {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. 1862forwell/pump and the Rules and Regulations of the San Joaquin Local'Health District. 'r'. +{ Job Address f 5� `� 1 " !�C/ G�i� �LYia/l/e S �tic�fp �3-'[ �zip City of Size PM Owner's Name O' T - Address 1� q C/2 •Z. Z I Phone s Contractor Address License No. Phone_ TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFIC ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o avation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public ❑ Other f Delta Depth of Grout Seal Type of Grout ❑ Irrigation x.'Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ype of Pump H.P. State Work Done Well Destru ❑ Well Diameter Sealing Material (top 50'1 ° Depth Filler Material (Below SO TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ -DESTRUCTION (No septic system permitted if public sewer is I I available within 200 feet.! Installation will serve: Residence v Commercial_ Other i Number of living units: Number of bedrooms z s Character of soil to a dep of 3 feet:I. Water table depth SEPTIC TANKType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest- WeIE 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. _ . -4 . - 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 i 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 a licant must call for all required ' spections. Complete drawing on reverse side. Signed Title:hj]tDate: �i - .- ��d FOR DEPARTMENT USE ONLY Application Accepted by Date Area :D� Pit or Grout Inspection Date Final Inspection by Date Additional Comments: �Y\ — ❑ Stk 466.6781 ❑ Lodi -3621 ❑ Manteca 104 ❑ Tracy 835-6385 Applicant -_Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i. INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. 74� "r EH13-24 1REv. /H F0 S',CJ C� �V - r.� 7 c,,�+''� f EH 14-28 V �1++ .. y D 1. i 7LP� I