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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTWbISTRICT 1601 E..HAZEL—ION AVE., STOCKTON, CA Telephone (209) 466-6781' PERMIT EXPIRES 1 YEAR FROM .DATE,ISSU,ED (Complete.in Triplicate);rv ,_: 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.,. ,r,� ! t.•..-a. * ,, . Job Address �/ .. S }�1.l�, _ City . Lot SizeC�A Owner's Name Address Phone 9 61 Contractor's Name �- w1L-\ ;License No. N �?-�+ Phone. TYPE OF WELL/PUMP: NEW WELL ❑ WELL�REPLACEMENT ❑ DST Ti PUMP INSTALLTiON ❑ SYSTE EPA R ❑ OTHJPR DISTANCE TO NEAREST: SEPTIC TANK SEWS_ INES DISPO LD. P. LI E FOUNDATION AGRI TUBE WELL OT R ELL PIT /S PS INTENDED USE TYPE OF WELL PROBLEM R CONSTRUCTION P I TIONS V IN Z ❑ Industrial 0`Open Bottom ❑' tec Dia, of Well Exca� t _ ia. of Wel acing ❑ Domestic/Private J❑ Gravel Pack' 'T T Ty of Casing Specifications El Public ❑ Other D to D hof Grout S Type of Grout El Irrigation, /�4ppr x. D pt astern S ace Seal In Ile by Repair Work Done ❑ Type of mp OF H.P.- f State rc o e c " Well Destruction El Well Diameter w "'Sealin t top 50'1 ;Depth Fill at r' I {Below 501 Vy TYPE OF'SEPTIC WORK: NEW.,INSTALLATION<U--fiEPAI / TION IDDESTRUCTIO!w septic system permitted if public sewer is I ilable within 200 feet.) Installation will serve: Residence commercial ? ther Number of living units:� Number of bed�o Character of Isdil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity j 6.00 No. Compartments PKG. TREATMENT PLT- ❑ r Method of Disposal Distance to a as Foundation -3 Property Line !aa LEACHING LINE ❑ice. 8i Lengiri of linesTotal length/size FILTER BED Distance to iearestWell�0 ♦ Foundation Property Line SEEPAGE PITS{ ❑ Depth ' Size ;Nurn6er, SUMPS ❑ Distance to nearesi: Weil f=") Foundation - Property Line T # DISPOSAL PONDS ❑ 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 Iof'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 subcontracting 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- r-7, s of California." ' The applica call for req ed-in tions. pi wing o everse si e. � •-. f Sign Title: Date: s , s / FOR DEPA ENT USE ONLY / C,L Application Accepted by w I Date —!Y �/ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: CI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20.09, Stk., CA 95201 FEE i . INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. + EH 13-24 IREV.10/931 �i-' 145 EH 1425