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it y ii •�y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ],, - 1601 E. HAZE; TON AVE., STOCKTON, CA vG Telephone (209) 466-6781 > PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �f (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. II j 1 G ref Jbb Address • i ! �A>� Citi .-L Lot Size Sb PM i ip Owner's Name l`1kM 4' Address �� –7;LC`� Phone Contractor`. Address License No. Phone E TYPE OF WELL/PUMP: _ANEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ II PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANMTO NEAR PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUN • N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation ' Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy a of Casing Specifications M Public Ll Other Cl Delta Depth o ut Seai Type of Grout I l Irrigation —.-Approx. Depth i I Eastern Surface Seal Inst by Repair Work Done ❑ Type of Pump H.P. St ork Done Ifi r i Well Destruction ❑ Well Diameter Sealing Material ft.. 50'I Depth ' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION i.I DESTRUCTION (No septic system permitted it public sewer is i� i available within 200 feet) l Installation will serve: Residencei— Commercial_ Other" I Number of living units: Number of bedrooms Character of sail to a pth of 3 feet: Water table depth__.. SEPTIC TANK Type/Mfg Capacity XOD No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Ii Distance to nearest: Well Foundation Property Line— LE ACHING''LINE ineLEACHING'LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line o #SEEPAGE PITS I l Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL�PONDS ❑ I 1 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, 1 shall employ persons suhiect to workman's compensa- tion laws of California." The applicant ust calf fora r uir i pact ons. Complete drawing an r side. Signed X_...X � �s� J Title: Date: FOR DEPARTMENT USE ONLY Application'Accepted by Date �� Area Pit or Grout Inspec ' n Date Final Inspection by Date E— O ii Additions! Comment . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 C Tracy 835-6385 Applicant-'.Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 f 9i 1i FEE INFO AMOUNT DUE AMOUNT REMITTED C`SH RECEIVED BY DATE PERMIT NO. ♦ EH 13.24(REV.I i n 51 EH 14-26 Q.Or�j 4r r I� r.