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APPLICATION FOR PERMIT �. T 'SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.,HAZEL-T ON"AVE., STOCKTON, CA Telephone {209) 466-6781 � SAL IAEALI" PERMIT EXPIRES TYEAR FROM DATE ISSUED �NVIROMI-i/,61ERVIGES (Complete in Triplicate) Application ish aby 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. Job Address [(� a -3 Q Q cit �tit "E4i Size PM Owner's Name �L Address 1 I y l _ Phone Contractor L res�-Pp0 kX- / License No. Phone -' TYPE OF WELL/PUMP: NEVO WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U--- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL e`4- OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \`1l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exbavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing l Specifications r ❑ Public F1 Other CI Delta Depth of Grout;Seal Type of Grout _ I 1 Irrigation —.Approx. Depth l 1 fastern Surtac� Seal Installed by _ Repair Work Done {B�Type of Pump H.P. /�1 /� - State Work Done W f f Well Destruction ❑ Well Diameter 5 a' M eri It ), Depth er a er Ie ' TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) '}installation will serve: Residence— Commercial— Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity �. k No. Compartments PKG..TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines } I Total length/size FIL ER BED ❑ Distance to nearest: Well Foundation} Property Line 1 SEEPAGE PITS I I Depth Size I Number t SUMPS Ll Distance to nearest: Well Foundation! Property Line DISPOSAL PONDS f] t I hereby certify that ave pre red this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regular ns of the San Joaquin Local Health Jp4trict. i Home owner licensed agent' signature rtifies t fo owing: "I certify that in the berformance of the work for which this permit is issued, I shall not employ any rson in such n as to bje to orkman's compensation laws of California." Contractor's hiring or sub-contracting signature ` certifies th Oil : "f c r hat in a the work which th' pe it is issued,I shall employ persons subject to workman's compensa- tion Laws f Califor ia." The appli ant ftl/� all fo I req ti s:-Co plate drawing ot5(e�__ d i Signed.- _ f /� Title: . Date: �� M1 FO DEPARTMENT USE ONLY Application Accepted by Date `7,7 Area [/ Pit or Grout Inspection by Date Final Inspection by Date f ? Additional Comments: LJ Stk 466-6781 LI Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 If Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. +,EH 13,24)REV.v/H!51 EH t42a