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APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone 12091 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.649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address —f A) City Lot SizeJ�x//d PM Owner's Name Address - f. � 5 Phone " w �_ _ X539 372 Contractor/ AX.Address 7 TYPE OF WELL/PUMP: V NEW WELL ❑ T WELL REPLACEMENT ❑ DESTRUCTION ❑ 7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD.*- `-'PROP. LINE . 1 FOUNDATION AGRIGULTURE WELL OTHER WELL f PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS.; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Well:Casing Ll Domestic/Private ❑ Gravel Pack ElTracy Type of Casing �� Specifications ❑ Public 11 Other O Delta Depthof Grout Seal ' - Type of Grout— n Irrigation --Approx. Depth` ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ %Well Diameter a Sealing Material (top 501 } Depth) Filler Material (Below 50') ' O TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT ❑ DESTRU ION INo septic system'permitted if public sewer is availabl within 200 feet.) Installation will serve: Residence_ Commm ercial_ Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: t Water table depth fi SEPTIC TANK j ❑ Type/Mfg ► Capacity I No.iCompartments PKG. TREATMENT PLT. ❑ Method ai Disposal „ Distance to nearest: Well Foundation Property;Line t LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest:--Well """" Foundation `"j Property Line ' SEEPAGE PITS .O? Depth Size Number SUMPS ❑ :. Distance to nearest: Well Foundation" _.-Property-Line— DISPOSAL ._P_roperty..Line -- - -, +- k 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 owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner:as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"l-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 E r The applicant ust•call for aU equired in ctions. Complete drawing on reverse side. I: Signed Title: Met J _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date a w�ea Pit or Grout Inspecti y Date Final Inspection by Date Additional Commen ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT DUE s AMOUNT REMITTED CASH RECEIVED BY DATE �PERMIT'NO. ti a EH 13-24(REV,1/H s) EH 14-28 i