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tloqy APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � �, 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781, , . 87 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � 3� i (Complete in Triplicate) GNVIROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein rei6E3!/ +Shin 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 f�-�_—�,_rA- y` " r` _ _ City Lot Size PM fj / ` �-c,��{%{- I- 2 Lglf Phone— 1 �� Owner's Name1 �✓° • s Address y�� Contractor ( &fjAddress 1`�.C1-' f -7�-7 q License N ra i �.� �j Phone _ TYPE OF WELL/PUMP: NEW WELL-0, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS XN ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r { ❑ Domestic/Private ❑ Grave! Pack ❑ Bracy Type of Casing Specifications M Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L? Type of Pump H.P. State Work Done _ t-4--go� Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 M RETYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DE=STRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Resid_ence_ Leommercisl Other.-. — Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: M Water table depth i SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments PKG, TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth E Size Number 1 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j hereby certify that I have prepared this application a sd 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 a ent's signature- l certifies thefotlowin 1 gg: "I certify that in the performance of the work"for which this permit is issued, I shall not M employ any person in such manner as to become subject to workman's compensation laws of California."j 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." ! I The applicantrc st c I for all required inspections. CcImpletedrawing on reverse side. 7 Signed X_ c� oy+.,� I S`�Title: / -- Dater 3C�•`� __ / FOR DEPARTM NT USE ONLY � - . , Q� 1 Application Accepted by Date r - in-, �/- Area Pit or Grout Inspection b Date Final Inspection by L�" �'�`r� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE k INFO AMOUNT DUE AMOUNT REMITTED. CASH CK RECEIVED BY DATE PERMIT'NO. ? l ♦ EH1321(REV.1 i n 9) L&a EH U-28 / Q�