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c APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA f�D � y Telephone (209) 466-6781 / PERMIT EXPIRES '!'YEAR FROM DATE ISSUED �p / (Complete in Triplicate) �o 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. y 3/ /y0 A 7� Job Address _ City of Size PM l Owner's Nam Address �C O a� !7' Phone o I� Contractor I Address �3l !7 O�"u'i License No. Phone/ T Q 6 k TYPE OF WELL :. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER ❑ (1- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V+Ii I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS {� r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing t ❑ Domestic/Private ❑ Gravel Parck 13T aacy�r.rr.w..r.. Type-of Casing �-- -- Specifications (I Public n Other � niastern t Ita Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth l Surface Seal Installed by _ t Repair Work Done 0 Type-of Pump H.P. State Work Done Well Destruction ❑ --Well Diameter Sealing Material (top 50') yy Depth r Filler Material (Below 501 A TYPE OF SEPTIC WORK: NEW INSTAL-LATION.(.I REPAIR/ADDITION L1 DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) Installation will serve:.. iie:. ,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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Methodfof Disposal Distance to nearest: T Well Foundation Property Line LEACHING LINE 0 No. & Length of lines " FTotal length/size FILTER BED ❑ Distance' nearest: Well Foundation f Property Line Y} i SEEPAGE PITS I I Depth rl Size Number a SUMPS ❑ Distanc 'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 1 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 I 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 applican must call for all required inspections. Complete draw o reverse side. Signed X , Title: ~ I - i FO MENT USE ONLY Q Application Accepted by __ QAai. �� Date � "K7 Area Pit or Grout Inspection by Date Final Inspection by Date1, 1 Additional Comments: 0 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 FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE /yPERMIT NO. r EH 124[REV.i/x 5) EH 14-4-29