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t ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT +• 1601 E. HAZELiLON`AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAWFROM DATE ISSUED ` (Co'mplete''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 Ryles and Regulations of the San Joaquin Local Health District. Job Address—_ �1.•✓g'►�`"r-^5 '�i/ '' 4 city i�d�"` La Size PM �'. Fall n1.9-. Mae.�f� Owner's Name � ' ti/ " f� �.�, Address _:. 2 s c"�r : csc'�4 Phone f Contractor�t�>�� - V47e Address.(pll�X LI i.'rAA) License No. ��' Phoneee -97 TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑j { DESTRUCTION ❑ R PUMP INSTALLATION ❑ SYSTEM REPAI"R'Oti OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I i INTENDED USE TYPE OF WELL "PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑yTjacy"---Type of Casing �' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ` r i v Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top-50=) It - J. y Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I C available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units:—/_ Number of bedrooms Y f Character of soil to a depth of 3 feet: ` Water table depth _Y SEPTIC TANK ❑ , Type/Mfg p ity � No. Compartments PKG. TREATMENT PLT. ❑ f�" ,Tis f71f ^a/ ..� Method of Disposal Distance to nearest: Well f� FZ.ndation Property Line I , j ti I Ia .r Total LEACHING LINE ❑ No.'& Length of lineslength/size , � FILTER BED ❑ Distance to'nearest: F Well `" Foundation Property Line SEEPAGE PITS ❑ Depth .L Size Number SUMPS ❑ Distancebto 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 ordlnances,state laws, and rules and regulations of the San Joaquin Local Health District. j N �T-/ 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." "The applicant must call for all required inspect' s. Complete drawing on %rreverse side. { Signed Title: r�,z� 't Pate: R DEPARTiNENT USE ONLY f " Application Accepted by Date � �� Area ` Pit or Grout Inspection by "` Date Final Inspection by Date —� Additional Comments: ❑ Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- " 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 CK RECEIVED BY DATE PERMIT"N0. INFO CASH + EH 13-24IREV.7/a51r- F EH 1426