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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (Complete in Triplicate) pp, p lication is Application is hereby made to the San Joaquin Locale Health District far a permit to construct and/or install the work herein described. This app 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 'ro cal Health District. Job Address City � x Lot Size- S� ) ) Q _ PM G 3 G Owner's Name EIS.Address — Phone ��.�-„ C7 / S Address N, �Q/]� 'T License No, T��Y7� Phone _ 97 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTA ELATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK WER LINES * fi __ _ ._ DISPOSAL FLD. PROP. LINE FOUNDATION AGR ULT URE L OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS I Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Ll Trac Type f Casing Specifications LI Other Cl to Depth of out Seal Type of Grout - I'1 Public ' I I Irrigation —.-Approx. Depth-- I Eastern r Surface Seal Installed by - Repair Work Done ❑ Type of Pum pr H.P. State Work Done _ q Well Destruction ❑ Well Diameter Sealing Material Stop 501 �f j Depth Filler Material iBelow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION lay REPAIRlADDITION I 1 DESTRUCTION ,(No septic system permitted if public sewer is b.- - - _available within 200 feet.) Ile Installation will serve: Residence ✓% Commercial— Other f Number of living units: ---/— Number of bedrooms y7,r- Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Well Foundation Property Line �I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance,to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth -Size Size Number SUMPS Ll Distance to nearest:__war'' Foundation 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 rules and regulations of the San Joaquin Local Health Diltrict. that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify 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- j tion laws of California." 1 - III The applicant must call for all required inspections. Complete drawing on reverse side. I Date: Signed X -Title:— - FOR DEPARTMENT USE ONLY = Application Accepted by Date Area Pit or Grout Inspection bye -=J-- ,Date - ` Final Inspection b Date t ' Additional Comments: ❑ 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 2009, Stk., CA 95241 I FEE AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ..EH 1324 TREY.i/H 57 EH 14-26 I —