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L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r , 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 ' (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. ! i Job Address ` >� (AMPIR A6 City &MON Lot Size�a ��fn PM I a Owner's Name C r i 1> Address (, VAL Q Phone � Contractor 'Y& r �- 1Jt%�ICiffAddress License No. Phone s TYPE OF WELL/PUMP: !i. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P SMP IN ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINESER AL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHWELL PITS/SUMPS INTENDED USE TjYPE OF WELL P BLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing Specifications JI. ♦ a 1-1 Public L Ll Other �❑ Delta Depth of Grout Seal Type of Grout _ I i Irrigation uM'..Approx, epth I I Eastern Su ce Seal Installed by Repair Work Done ❑ Typie pof mp H.P. State Work Done Well Destruction ❑ Well 1 eter Sealing Material (top 50') Depth Filler Material i8elow 50') TYPE OF SEPTIC WORK: NE W INSTALLATION I 1 RI i IRlADDITION 1.1 DESTRUCTIO [Na septic system permitted ifpublicsewer is available within 200 feet.I, Installation will serve: Residence_ Commercial_ Other Number of living units: ! Number of bedrooms Character of soil to a depth:o f 3 feet: r Water table depth SEPTIC TANK ❑ I:Tl ype/Mfg Capacity No. Compartments n PKG. TREATMENT PLT.. ❑ J! Method of Disposal U ' Distance to nearest: Well Foundation Property Line IIM _ ^r - LEACHlNG LINE Ll nNo. & Length of lines Total length/size FILTER BED ❑ 'Distance to nearest: Well 4 Foundation Property Line € SEEPAGE PITS I'1 Depth Size Number / SUMPS L- �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 Y rules and regulations of the San Joaquin Local Health District. (� Home owner or licensed agents 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." ilil The applicant must arall Jor aE quired inspections. Complete drawing on reverse side. Signed _ Title: 0L_U 6-- 1 Date: V II� FOR DEPARTMENT USE ONLY [� 1 �-, f b _f Application Accepted by c �� Date C Area p p Pit or Grout Inspection I� Dari Final Inspection by Date !4 .� t�t'J V,Additional Comments: 'f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 xi Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k INFO FEE °MOUNT DUE AMOUNT REMITTEDCKRECEIVED BY DATE PERMIT'NO. .�.+.EH 13-24(REV.r/x 51 ' !yf-/, `/},�./ , d ;(y( A73-1 EH 14.26 /dS /lEUU