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} APPLICATION FOR PERMIT � �jWe7° SAN JOAQUIN LOCAL HEALTH DISTRICT EIVjED 1601 E. HAZEL T ON AVE., STOCKTON, CA MAY 0 9 17P.a1 Telephone (209) 466-6781pu$NjOAQU1Nca NrV PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRO MENTAL ScpVICES (Complete in Triplicate) AL NEg0H DIV1$11)�. Application is hereby made to the San Joaquin Local Health District fora 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 7 7City Lot Size PM j, Owner's Name Address. Phone Contractor AddressOS� License No. PhonJJf Oj TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ©J SYSTEM REPAIR ❑ OTHER ❑ DISTANC _TO NEAREST: SEPTI_C,TANK. _ _ SEWERYLWESw DISPOSAL FLD. .PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL P7 FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑� trial 13Open Bottom D M teca pia. of Well.Excavation Dia. of Well Casing L�Domestic/Private ❑ Gravel Pack kTracy Type of Casing Specifications 1'1 Public [1 Other V 71 Delta Depth of Grout Seal Type of Grout I Irrigation _,_Approx. Depth l I astern Sof ace Se I tailed by Repair Work Done ❑ Type of Pump �' H.P. / _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 n TYPE OF SEPTIC WORK: NEW INSTAEATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is d available within 200 feet.) O Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet:A Water table depth SEPTIC TANK ❑ Type/Mfg'I Capacity No. Compartments PKG. TREATMENT PLT. ❑ ( Method of Disposal 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 Size Number pb- SUMPS 'CI'"-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 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 persons subject to workman's compensa- tion laws of California.'. The applicant must call fo all required inspections. Complete drawing on reverse side. J Signed X Title: Date: FOR DEPARTMENT USE ONLY 12L �o Application Accepted by Date Area Pit or Grout Inspection by Date Final lnspection'by Date Y51- Additional 5 �7 t Additional Comments: CJ Stk 466-081 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 335-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE i AMOUNT REMITTED CAS- RECEIVED BY DATE PERMITN0. + EH13.24(REV. 51 R .tsYv C EH 10-28 ^� > /p+ // "' In _ J