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�v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA ,,� � Telephone 1209M 466-6781- PERMIT 66-6781PERMIT 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. Job Address LA I W City Lot Size 3 L -LA% q pm 19 1-a4 0�11 Owner's Name \ Address Z hone 2� Contractor _f Address License No. Phone_ TYPE OF WELL/PUMP: „� NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ D18TANCE TO NEAREST SEPTIC TANK SEWER NES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E WEL OTHER.WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di . Well EzcairationDia. of Well Casing ❑-Domestic/Private ❑ Gravel Pack ❑ Tracy .Y. _ ype o asingSpecifications 1'1-Public r"a ' ❑-Other i# 4~ FIDelta Depth of out Seal Type of Grout Q i I I Irrigation _.yApproz, Depth, I I Eastern Surface Seal stalled by r Repair Work Done ❑• Type of Pump F -H• r F 'State Work Done_ ` Well Destruction ❑ Well Diameter eating Material It op 50'1 ` ! Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I.) DESTRUCTION fNo septic system permitted if public sewer is vailable within 200 feet.) -Installation will serve: Residence `_ Commercial_ Other Number of living units: {Number of bedrooms _ Character of soil to a depth of 3 feet: T Water table depth SEPTIC TANK ❑ Type/SMfg 1' Capacity No. Compartments PKG. TREATMENT PLT. ❑ j r Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ° I I Depth t Size Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS '^ ❑ I hereby certify that I have prepared this application and that the woik 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. 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" y pe p p y persons subject to workman's compensa- tion laws of California." The applicant must call for all squired inspections. Complete drawing on �rse 7 Signed X�7.N _rz�y � Title: Date: -9 6 _ A rFOR EPAHTMEpIT U.SE_ONLY Application Accepted by f?�C}... 1M Date �a�a �7 . Area �. Pit or Grout Inspection by Date Final inspection by do_c..,,.�. -Date'- Additional ate-Additional Comments: t ❑ Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services1601.E._Hazalton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'No. + EH 13-24 IREV.i/+t 51 EH 1 4-26, .. ...