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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,;STOCKTON, CA N© W .L-�- pW>ru�Y' Telephone (209) 466-6781 j1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i t (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 applicafi8ri 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 J �J� k�: /// ns"f - City Lot Size S ^ 1 PM + Owner's Name Address �~-?/u Phone �' "^� `Q'L 11 Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ UMP INSTALLATION ❑ SYSTEM REPAIR E3OTHER'❑ DISTANCE TO NEAREST: SEP NKr SEWER LINES DISPOSAL FLO. . LINE FOUNDATION AGRICULTURE WELL O LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excav ` Dia. of Well Casing y T _. ❑ Domestic/Private ❑ Gravel Pack F ❑ t�o Type`of Casing Specifications ❑ Public 171 Other Delta Depth of Grout Seal a pe of Grout y ❑ Irrigation �.fp.-.-: epth ❑ tern Surface Seal Installed by i Repair Work Done H.P. State Work Done_ ,1 Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 t _ Depth I Filler Material IBelow-50''_)_ �_ TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑ REPAIR/ADDITION ❑ -'DESTRUCTION (No septic system permitted if public sewer is r{ available within 200 feet.► Installation will serve: Residence Commercial_ Other + Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: j ' Water table depth t SEPTIC TANK ❑ Type/Mfg Il " Capacity No. Compartments PKG. TREATMENT PLT. ❑ € Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑f No. & Length of fines Total length/size Il t, FILTER BED _ ❑ Distance to.nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 11 "SizeNumber -y SUMPS ❑ Distance to nearest: --�rFWello`undafionr 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) i 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." p ant must call for all required ins ctions. Complete drawing on reverse side. , Signed X .Title:x` �•M1V�R�� _ Date: F EPARTMENT USE ONLY r� t�v�Application Accepted by Date_—_ Area Pit or Grout Inspectio by Date Final Inspection by fP ea- Date 1 Additional Comments Wr' ❑ Stk 466-6781 ❑ Lodi 369-3511 .f Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk.,-CA 95201FEE INFO AMOUNT DUE i! AMOUNT REMITTED CASH n RECEIVED BY. DATE PERMif NO. + EHt3-24/REV.}iR5Y rr 06 ' ' EH 14-28 �`J ♦ Q d �' 1�/g 1 i