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I 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. Job Address 1 '50 G1-1- rLj -��' City�L/�, Lot Size PM Owner's Nam e M, 13. Address .2 Jrfr`t Phone�71� Contractor I�I Address License No. Phone TYPE OF WEl(L/PUMP: NEW WELL ❑ „WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS�LFD. PROP. LINE FOUNDATION AGRICULTU ELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial f�r LJ Open Bottom LJ Mar ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/((Private ❑ Gravel Pack racy Type of Casing Specifications ('l Public F] Other F] Delta Depth of Grout Seal Type of Grout 9 I I Irrigation �� _..Approx. D th ( I Eastern Surface Seal Installed by - J Repair Work Done ❑ Type of Pu H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') -- III' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is II vailable within 200 feet-1 installationl144will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character dlf soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal illDistarice to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEDJJ�, ❑ Distance to nearest: ' Well Foundation Property Line iI SEEPAGE PITS { I Depth Size Number SUMPS �I L1 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 ownerildr 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 applicanllmust call for all required inspections. Complete drawing on reverse side. p� Signed I Title: _*��Q.[-�.i; s7�� Date: .� '� p 7 v i� FOR D TMENT USE ONLY Application Accepted by - Date ! pB—73�7 Area 16 'll. k. r v8 Pit or Grout inspection by f� Date .Final Inspection byDate Additional Comments: 'r l El Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO /� m CASH ^ry r EH13-24{pEV,tin51 �'9,� EH 14-28 i� ✓