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a M APPLICATION FOR PERMIT 04�-5 ` SAN JOAQUIN LOCAL HEALTH DISTRICTND WV 'D"s�+� " 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ��, /_ l t PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED p _ (Complete in Triplicate) fUr7 t - 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. w i E Job Address Zzo City Lot Size PM t Owner's Name LL }/!�►/ cS/ Jy&Cadress Phone oContractor S Address . License No. Phon m� ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR a OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHE S INTENDED USE TYPE OF WELL PROBLEM AREA CTI IONS _.❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation ia. of Well.Casing \ ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing , Specific s A ('l Public ❑ ❑ Delta Depth of Grout Seal T ' a Type of Grout _. i I Irrigation —..Appmo . Depth { I Eastern Surface Seal Installed by' _ Q Repair Work e Type of Pump H.P, _ State Work Hone ' Well ruction El❑ Well Diameter Sealing Material (top 50') Depth r Filler Material (Below 501 Y- TYPE OF SEPTIC WORK: NEW-INSTALLATION-(l REPAIR/ADDITION.[1_ DESTRUCTIONI }No septic system permitted if public sewer is ' available within 200 feet.) 5 Installation will serve: Residence s Commercial_ Other c Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth { SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ y Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line 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, 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 foriowing: "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." The applicant m st call for all required inspections:Complete drawing-on re erse slda. Signed X� J�� c � d Title: Date: v -�-----rte F PARTMENT USE ONLY Application Accepted by {� Date Area © a� i Pit or Grout Inspection by Date f=inal Inspection by Date? Additional Comments: ❑ 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 f FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. ' + EH 13-24 IREV.I/H 51 �` Qy� EH 14.26 ! (Jl l