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g£ 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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. / / � sryy Job Addressr � � �� City `„� Lot Size PM Owner's Name CdOrI £Aw 16�M�Address �� /� Phone G� ! Contractor �`�RITlf4e Address 3e--Cfdl'y` License No. 2 �� Phane TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ > PUMP-INSTALLA-TION-I] SYST-EM•REPAIRIEI -s OTHER ❑ DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -,_FOUNDATION AGRICULTURE;WELL - OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT! ATIONS ❑ Industrial ❑Open Bottom [I Manteca all Excavation ` Dia. of Well Casing + ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications F] Public C) Other F] Delta Depth of Grout Seal Type of Grout h I I Irrigation ox. Depth ,i I Eastern Surface-Seal Installod.by,. _ \� Repair Work Done . J ype of Pump r H.P, t r } State Work Done_ i? Well Destructio ❑ Well Diameter r ' Seali g Material (top 50') r Depth ' Y Filler INaterial f Below 50'I t TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION)( !DESTRUCTION'[ i INo septic system permitted if public sewer is `-available within 200 feet.) Installation will serve: Reside nee Commerciah 7 Others a Number of living units: —/— Number of bedrooms Character of soil to a depth of 3 feet: _� d Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity T _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to-Trearest: i Well Foundation Property Line LEACHING LINE 4I--No. & Length of lines r Total length/size r FILTER BED ❑ Distance to*neare't: Well Foundation a Property Line ' Z� SEEPAGE PITS I I Depth Size � ; -:"'Number r SUMPS Distance to nearest: Well o00'-4 Foundation '_ Property Line L� DISPOSAL PONDS ED I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquiri county ordinances, state laws, and 1 rules and regulations of the San Joaquin.-Local_Health,Di$trict, ». 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 c for all re ire pe s. Complete drawing on reverse side. Signed X 1 Title: Date: I PASTMENT USE ONLY Application Accepted by date Area { Pit or Grout Inspection by Date Final Inspection by Date 3 U r 1 Additional Comments: P ❑ Stk 466-6781 ❑ Lodi 369-3621 l ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEE )NFO AMOUNT DUE 1, AMOUNT REMITTED CASH RECEIVED BY DATE PERMWNO. r-EH 13-24 iREV.i/A 51 1 �� EH 14-28 in, -