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x l APPLICATION FOR PERMIT F SD SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., STOCKTON, CA Telephone (209) 466-6781 I. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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. a i �,<. ,�a •, �,/ l ,l ,. ' tomob Address �'' W ` � Ci Jty "Lot Size 1 �11+/7�,J�PM Owner's Name �[�t�Or/*-+► // 'rl�Address -30 1' ✓� '� _�_2/ti✓ Pfione ''?12-6 Contractor � Address License No. Phone a TYPE OF WELL/PUMP: * .. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . ...t PUMP INSTALLATION TEM AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTWELL OTHER WELL PITS/SUMPS r " INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS i Ll Industrial C1 Open Bottom ❑ Man a Dia. of Well Excavation Dia. of Well Casing 3 ❑ Domestic/Private ❑ Gravel Pack ❑ acy Type of Casing Specifications 4 ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout ❑ Irrigation �Approx. Dep ❑ Eastern urface Seal Installed by _ f Repair Work Done ❑ Type of Pump N.P. 7 +�4 State Work Done j Well Destruction ❑ Well Diamete Sealing Material (top 50') Depth I Filler Material (Below-501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION/K iNo septic system permitted if public sewer is k, available within 200 feet.) Installation will serve:i Residence— Commercial_ Other 1 Numbeir of living units: Number of bedrooms Character of soil to a depth of 3 feet) Water table depth SEPTIC TANK ❑ Type/Mfg t Capac No. Compartments PKG.°TREATMENT,PLT. ❑, F Method of Disposal ,- Distance to;nearest: WI- undation-. Property Line LEACHING-,LINE," . ❑ No. & Length-6f lines ""� Total length/size I FILTER BED ❑ Distance;to nearest: I Foundation Property Line i f t SEEPAGE PITS-"` LlDepth Size Number_ SUMPS ❑ Distance.to nearest:., Well Foundation. Property Line r 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, an ' 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 a performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c for,all required in ctions. Co ete dtawing on reverse side. Signed XaL Title: Date: 6 I 1 y FOR DEPARTMENT USE ONLY F �� + r + Application Accepted by Date ~a Area r Pit or Grout Inspection by Date Final Inspec' n by Date Additional Comments: " ai ❑ Stk 466-6761 ❑ Lodi 369-3521 ❑ Manteca 823-77Y54Q. ❑ Tr cy 835-6355 h o ,Applicant- Return all copies to. Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201�r//►�/ �~ INFO AMOUNT DUE J AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. f� +-EH 13-24(REV.i/a 5) J ✓' ` EH 14-20