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F APPLICATION FOR PERMIT � i. ' ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH (Complete in Triplicate) F141f1R0,0ENT1- �rlsF<Rvic�.s Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work Ink bed.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. r y Job Address �O ` ' Cr pf r&t City A-C Lot Size PM Owner's Name fira 1114 ``/4G ` Address p G� • a y ol-Phone }� J. /< 1. Phone 2i°FA F Contractor r �'�r Address i i'O License No. TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _C 5-c— SEWER LINES DISPOSAL FLD.0_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing f ED Domestic/Private Gravel Pack y4racy Type of Casing Specifications Type ❑ L1❑ Public Other Delta Depth of G e..� rout Seal _ Type of Grout ❑ Irrigation -t(9L_Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 X TYPE OF SEPTIC WORK: NEW INSTALLATION L1REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is C�1 available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth } SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments � /, PKG. TREATMENT PLT. F] Method of Disposal �J Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 9 r 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "1 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 applicant m tail for"all r uire s ctions. Complete dr ing on ta /�/ Signed Title: O EPARTMENT USE ONLY �7_! Application Accepted by a.A,AA Date t i 4� — Area �C-_ _k Final Inspection by Date Pit or Grout Inspection by Date Additional Comments: ❑ Stk 466-6781 C� Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,, CA 93201 FEE DUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH13-24IREV.S/651 f �� X17 EH 1428 L 014 (1. Llyr 1