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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZEL T ON AVE., STOCKTON, CA IVO LrJ rz�YCv, Q#C�01r Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 Health District. /I00 Job Address � s � / _ [/ Cit Lot Size PM Address Phone 2� Owner's Name - �-y Address License NhoContractorlkyZ n -� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �• m PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONST ECIFI CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications I"1 Public C1 0 {� Delta Depth of Grout Seal Type of Grout 1 1 lrrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair r Done ❑ Type of Pump H. P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial .T 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 9 LEACHING LINE ❑ No. & Length of lines Total length/size FILT17R BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll 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."Contractors 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 haws of Ca-fornia." The applicant ust call all required inspections. Complete drawing on reverse id Signed X Title: Date: R DEPA ENT USE ONLY Application Accepted by Date J Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ S tk 466-6781 ❑ Lodi 369 621 ❑ Manteca 823-7104 J T cy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K INFO C H RECEIVED BY DATE PERMIT NO. / p a EH 13-24 IREV.t/»51 U u r U V F(q EH 14-26 v itt