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APPLICATION FOR PERMIT ``z SAN JOAQUIN LOCAL HEALTH,DISTRICT 1601 E. HAZELTON;AVE., STOCKTON, CA , r Telephone (209) 466-6781 PERMIT,EXPIRES TY.EAR FROM DATE ISSUED IComplete 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.. Doti Address Sr Lot Size �/J�_ &r-- PM J _ city F Z , Owner's Name dt " add Address A,2g I 4;�P^f e ez i ,2 � �Phone 7 � 3 Contractor �� -_ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTA TION ❑ SYSTEM REPAIR OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU ELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PR LE A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom.- ❑ n a Dia. of Well Excavation Dia. of Well Casing m ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation _.A oz.{Depth I Eastern Surface Seal Installed by - Q y Repair Work Done E Ty of Pump H.P. State Work Done _ v Well Destruction 17Well Diameter` Sealing Material (top 501 i Depth ' Filler Material-'(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l'I REPAIR/ADDITION ( I DESTRUCTION (No septic system permitted if public sewer is y i I )` available within 200 feet.) Installation will serve:. Residence I Commercial Other.- I Number of living units: Number of bedrooms r 1 Character of soil to a depth of 3 feet:l Water table depth V- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments fv}J PKG. TREATMENT PLT. ❑ Method o1 Disposal k Distance to nearest: Well Foundation Property.Line k I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER 13ED ❑ Distance to nearest: ' Well Foundation Property Line i SEEPAGE PITS l 1 Depth I Size Number {�} SUMPS LZ Distance to nearest: t- Well Foundation Property Line + b DISPOSAL PONDS ❑ 7 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, f 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." I The applic ust �for �req ' �insct�ito . �mpleterawing on reverse side. Signed X Title: 4dm � Date: € FOR DEPARTMENT USE ONLY Application Accepted by Lys - Dat Area Pit or Grout Inspec' �. Date Final Inspection by + Date"11" �8 Additional Comments: �� , -L C- - !r G4 L_) ❑ Stk 466-6781 ❑ 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 A FEE AMOUNT DUET AMOUNT REMITTEDCASH RECEIVED BY! DATE PERMIT'NO. INFO ♦.EH13-24iREV.tiH51 £H 14-2e