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-- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) or a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Health District f I 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. r Job Address r s �J/v V City� c Lot Size PM Owner's Name `�''z� Address _ ��`-'.,�� yd Phoned Contractor Address License No. Phone l PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATI -'r❑ SYSTEM 1PAIR ❑ OTHER D ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR ELL_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE RE CONSTRUCTION SPECIFICATIONS } 11 Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac -Type of Casing� Specifications (`I Public ❑ Other 1 17 Ila : pth of Grout Seal Type of Grout I 1 Irrigation —_-Approx. Depth I EasternSu a Seal installed by - Repair Work Done L-1Typeof Pump H.P. State Work Done _ r Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth ri Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t 1 DESTRUCTION l INo.septic system permitted if public sewer is +W I } available within 200 feet.), Installation will serve: Residence's Commercial= Other LA Number of living units: Number of bedrooms # �, Character of soil to a depth of 3 feet: x Water table depth SEPTIC TANK ❑ Type/Mfg ty No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal I Distance to nearest: Well Foundation Property Line ze% th/siLEACHING LINE ❑ No. & Length of lines Total len 9 _ FILTER BED ❑ Distance to nearest: Well F o�unda-tio'n—=7 Property Line SEEPAGE PITS F I Depth Size N Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k 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 I 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 follow' : "I certify that in the performance of.the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- I tion laws of Cali r a." i f The applicant t call for 11 re fired i ctions. Complete drawing on reverse side. 'I4LA / Signed X ! Title: Date: p FOR DEPARTMENT USE ONLY ` Application Accepted by � Date `� �� Area Pit or Grout Inspection by 1 DatFinal Inspection by Date Additional Comments: F I-STErna (Oq`f� W❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Envir nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. IM NFO � ♦ EH 13-24IREV.iin5) ��. �Q 1 3 6 ��`Y �/ '� • "��1 EH 14-26