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4 APPLICATION FOR PERMIT SAN JOAQUIN1OCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone 12091 466-6781 � fJ f k ' PERMIT EXPIRES 7 YEAR FROM DATE ISSUED s a' (Complete in Triplicate) Wo y i Application is hereby made to the San_Joaquin Local Health District for a permit to construct and/or install the work hereindescribed,+ is i made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the Sa Local Health Di"strict. This application is 3- San Joa uin q Job Address ,I w, r T. City Lot Sizes�� r PM Owner's Name '�c, cy -Address - CAl Phone 22 Contractor Address CJI Q ;. I TYPE -- WELD UMP: NEW WELL ❑ License No. / Phonef ` PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DEST13UCTION ❑ "' i DISTANCE TO NEAREST: SEP 4IC.TANK SYSTEM REPAIR El OTHER [I ` --� SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP' LINE INTENDED USE `' OTHER WELL—�� PITS/ TYPE'OF WELL PROBLEM AREA ❑ Industrial � CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' 11 Domes' ❑ Grawel Pack Dia. of Well Casing ❑•Public � ❑ Other ❑ Tracy Typo of Casing ,. #f F1 Delta Depth of Grout Seal Specifications ❑ Irrigation f ' l pprozDepth ❑ Eastern Type of Grout —� : Repair Work Done Ll T Surface Seal Installed by Type of Pump_ H.P. ----------- 'Well � Destruction ❑ Well Diameter ' State Work Done_ . :- Sealing Material (top 50') r Depth �`I Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if publics f '4 { Installation will serve: Residencrl !�' available within 200 feet.) ewer is Commercial` Other Number of living units: Numfier.of bedrooms' Character of soil to'a depth of 3,feet: SEPTIC TANK ".�`rs -sf�pe%Mf' y Water table depth PKG. TREATMENT PLT. ❑ (+ Capacity. F No. Compartments Distance io nearest:'- Well Method of Disposal Foundation —� Property Line LEACHING LINE ` "f I No:& Length of lines j.. ,,,, f- t". FILTER BED 1 ❑ Distance to nearest: yly/l 1 1�.�1/ I Total length/size �F, { " -�� oundatio�n � Property Line SEEPAGE PITS } � Depth Size �' . SUMPS w Number 4' ❑ Distance to nearest:' Well Foundation �- �....;,- T t DISPOSAL PONDS ❑ r ° t Property Line_ I hereby certify that I have prepared.this.application and that the--work will be done in accordance with San Joaquin court rules and regulations of the San Joaquin Local Health District- Home owner or licensed agent's signature certifies the foUowin E A ri,,ordinances;state laws, and employ _"g: '1 certify that in the performance of the'work for which this p Y 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:"!certify that in the permit is issued, I shall not tion laws.of California." T� i Performance of the work fo�which this permit is issued, I shall employ persons subject to workman's compensa- . V t The applicant must.caA for requi tl inspections:C-omplete_drawing on reverse fide ��T Signed X Title:" / { � Date: FO USE-ONLY---f Application_Accepted by -4 Dat Date "V I Pit or Grout.lnspection by m Area Additional Comments; �1 Final Inspection by Date !�yL ❑ Stk 466-6781 ❑ Lodi 3693621. 1 ❑ Manteca 823-7104 f Applicant. Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P O. Box 2009, Stk., CA 95201 FEE f INFO AMOUNT DUE" AMOUNT REMITTED C RECEIVED BY DATE + EH 13"24 4REV.I/E si Z. PERMIT'N0. EH 14.28