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p APPLICATION FOR PERMIT SAN JOAQUWLOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA N® t'i�CLw�u�/ l Telephone (209) 466-6781 k; PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED t (Complete in Triplicate) EY' �'� �£v rw�.l�� • ~ 4 • 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 compliancewith 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:,;: - Job Address ( S �`�C �C �� Y City 'Lit Size PM Phe ��J'�' f Owner's Name !^� rJ Address 7 s ' Contractor •a Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. E FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS SPECIFICATIONS --- El Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing 1 Specifications ❑ Public ❑ Other ❑ Delta :Depth of Grout Seal r € Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Do Type of Pump H.P._; State Work Done Well.. ction ❑ Well Diameter Sealing Material (top 50') . ` Depth Filler Material (Below 50') " TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION i INo septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence_ Commercial_ 'Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 5 Capacity No. Compartments PKG. TREATMENT PLT. ❑ j Method of Disposal _ 1 Distance to nearest: Well �L Foundation_ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' a SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: µ Well Foundation Property Line DISPOSAL PONDS ❑ J 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 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. ' The applicantmu c II for all requireddin/s/peep�tions. Complete drawing on reverse,side.'`=.� Signed X6'G� �V�C�/T�"6� Title: v Date:,A ^ FO DEPARTMENT USE ONLY �] Application Accepted by L.x�1�. ',1M/7" � � Ste",— Date_�'""- 1�` S / Area CD l Pit or Grout Inspection by Date* Final Inspection//by ;Date Additional Comments: ��-"�,�'D *-►� Tc"`� �f� 1 G1�/_ ❑•Stk 466-6781 ❑ Lodi 369-3621 ❑-Manteca 823-7104 ❑ Tracy 835-6385 / s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:O. Box 2009, Stk., CA 95201 r . FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. + EH13.24(REV.1/85) SA �® � pry �� G^� y(, EH 14-28 .... . . �s - `�..,.f(O t - ,(LI. 4 1'- 1 1'