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E , t 3 APPLICATION FOR PERMIT ° SAN JOAQUIN LOCAL HEALTH DISTRICT 'h �L , 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED gi-6-C (Complete in Triplicate) J Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereirTdescribed. 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. t - �_Y - -15' Job Address 0 /v City Lot Size PM `� r - Owner's Name Adress �a`�`_ ��~ Phone d� Contractor !'' r Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL PROP, LINE A FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROS LEM AREA XMISTARUCTION SPECIFICATIONS' ❑ industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications R 1-3 Public Cl Other 17 Delta Depth of Grout Seal Type of Grout ., I I Irrigation vd -A Appr Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Ty ,Pumpj, H.P. State Work Done _ Well Destruction ❑ ell Diame`t'erl Sealing Material stop 50'► Depth Filler Material (Below 501 TYPE OF SkFfIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 0 DESTRUCTIO 1 (No septic system permitted if public sewer is" ryryry available within 200 feet.) 1 Installation will serve: ResilldLnce— Commercial_ Other t Number of living units: �I!` Number of bedrooms Character of soil to a depth.ibf 3 feet: Water table depth SEPTIC TANK ❑ hType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal ` ,Distance to nearest: Well Foundation Property Line J� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED" ❑ i�0istance to nearest:' :. Well Foundation Property Line SEEPAGE PITS l I Depth Size:_ Number SUMPS Cl '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 Stan Joa4uin 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." ' ,s. The applicant m St.call for require ns i ns. Com a drawing on reverse side. } p' f� 12—.Signed X 5 _ Title: - ' V" `14 �r�- Date: FOR DEPARTMENT Alnspetio dU � Application Accepted by - '— Area Pit or Grout Inspectio 01� Date Finy ic-:� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 --.,U Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INN •y'Lt� FEE AMOFUNT DUE AMOUNT REMITTED CK RECEIVED BY YDATE^ � PERMIT N0. INFO ` a.EH 17-241REV.1/H55 r=- EH 14-26 �I