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ik APPLICATION FOR PERMIT c�. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ik PERMIT EXPIRES TYEAR FROM DATE ISSUED 4 (Complete in Triplicate) f 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 C 6unty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r^p ! lD .v>,��+ PM 4 Job Address r L. City..-- Lot Size C� Owner's Name Address l� �' � - — phon �4— � " Contract? t Address `i(�7''-"� License N c Ot� Phon NEW WELL ❑ WELL REPLACEMENT 17e DESTRUCTION ❑ -. TYPE OF WELL/PUMP: _ _. __ - ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _dT FfE4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION -AGRICULTURE WELL OTHER WELt PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM•AREA.—CONSTRUCTION SPECIFICATIONS ❑ Industrial 11Open Bottom C5Manteca Dia. of Well Excavation Dia. of Well Casing (A ❑ Domestic/Private ❑ Gravel Pack L1Specifications Bracy Type of Casing _+1 r"1 Public ❑ Other 1-1/Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth ^_1Y1 Eastern It Surface-Seat Installed by. !, Repair Work Done ❑ Type of Pump H.P. State Work Done_ V Well Destruction ❑ Well Diameter ' ;Sealing Material Itop 501 Depth Filler`Malerial (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDJTION 1 1 DESTRUCTION I 1 (No septic system permitted if public sewer is 1' avail le within 204 feet.) Installation will serve:' Residence_ Commercial. Other Number of living units: Number f edro ms V E Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK Type/Mfg `` t * ' Capacity No. Compartments PKG, TREATMENT PLT. 11f t r Method of Di`posal Distance to nearest: Well Foundation Q Property Line 5 LEACHING LINE L� No. & Length of lines '! K Total length/size 6 FILTER BED ❑ Distance to nearest: ' Well M) 0 Foundation ..— Property Line s r SEEPAGE PITS t Depth Size Number SUMPS ❑ Distance_ to ne rest: Well Foundation /D t Property Line l DISPOSAL PONDS ❑ f ' 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 fo workman's,ompensation 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." , t The applicant m call for all uir inspections. Complete drawing on reverse I ned X Title: _V- r Date:/ Sig OR PARTNIENT USE ONLY k App ication Accepted by Date v � Area r � Pi or Grout inspection by Date / Final Inspection by Date Additional Comments: d . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca; 823-7104 ❑ Tracy 835-6386 jApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO f } + EH 13-24(REV.)/H 57 EH 14-28 tl