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1! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED b (Complete 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 Heal th,Olstrict. a I ••+ '- Job Address C �, y� City!� Lot Size PM Owner's NameAddress .�OJ� �4 PhoneC1i • ° '�� S 'J Contract N� E(,aD Addresskms'o �o7GS�"5 —LicenseZSPhone TYPE OF WELL/PUMP: it NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Optbn Bottom ❑ Manteca Dia. of Well Excavation +,Dia.of Well Casing O Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications [7 Public ❑ Other n Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ yy Repair Work Done ❑ Type of Pump H.P. State Work Done R Well Destruction ❑ Well Diameter _ Sealing Material (tap 50'I �. S Depth 11 s Filler Material (Below TYPE OF SEPTIC WORK: NEW.'I INSTALLATION I 1 REPAIR/ADDITION ESTRUCTION I I (No septic system permitted if public sewer-is `D available within 200 feet.) Installation will 52rve: Residence— Commercial Other Q, Number of riving units:I—;;Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Me:hod of Disposal f r Distance to nearest: Well Foundation-30?? Property Line I I LEACHING LINE No''& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt 4370 Ll Foundation Property Line J SEEPAGE PITS I I Depth Size _ Number—. SUMPS umber_.SUMPS ❑ Distlence to nearest: Well Foundation Property Line v 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 Diktrict. - - -.. . = Home owner or licensed agent's signature certifies the following: "I cen4y"that in the performance of.thework for which this permit is issued, I shall not employ any person in h manner ss to become bject to woriiman's comparisation laws of California."'Con!rector's-hiring orsub-contracting signature certifies the following: 1 certify tha4 in the perf nce bf the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califo i " Ii I .. ,1 _ .,.,,,,..—,................,._—_.".,.� The appli nt t II for all require ns ction Co eta ng on revers side. / Signed X �"�' Title: � Date: of FOR DEPARTMENTiUSE ONLY i Application Accepted by 1 Date Area ' t Pit or Grout Inspection by pate Final Inspection by Date 1��r?�R�I h I f H Additional Comments; ❑ Stk 466.6781 ❑ Lodi 369-3621• ❑ Manteca 823-7104 ❑Trdby 835`6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1' I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO_ f-EH113-241REV.t/Nsf .I� EH 114.26 �/� _ a