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APPLICATION FOR PERMIT f0 t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � P j Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /VU° /`0 —7d (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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. ! o Job Address 4_`'- A 44 �/C/� ,,,,.,,!—�� ✓✓✓ City Lot Size PM r l Owner's Name Address"" .te _i � Phone \ � nn J Contractor S Address CR' License No�aPhone TYPE OF WELL/PUMP: NEW WELLY WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST--FStPTIC TANK SEWER LINES DISPOSAL FLD. _- •-POOP:LINE y� 'j_FO IND; TION AGRICULTURE WELL ,-OTHER WELL PITS/SUMP-S k INTENDED USE TYPE OF,WELD PROBLEM AREA—CONSTF12TION SPECIFICATIONS }� O t Industrial. Open Bottom�ac �" .� � -F] Manteca � Dia. ft/VeH-E-cavation Dia. of Well Casin ❑ Domestic/Private. ❑-Gravel Packy- - Type of Casing �� Specifications_'--. _ ' 1-1 Public F1 OTther - Ll Delta Depth of Grout SealType of Grout p7 r 17 Irrigation q�-Approx. Dasternurface.Seal Installed by S J� -Repair Work Done ❑ Type of Pump H.-P: State Work Done If Well Destruction ❑ Well Diameter Sealing Material (top 50'I._t"` � Depth Flller Material (below 501 I TYPE Of SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITIOWLI DESTRUCTION I I (No septicsystem permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth{ ! SEPTIC,TANK p Type/Mfg ! Capacity 4 No. Compartments F PKG, TREATMENT PLT. ❑ r 1 . Method ofrDisposa!' Distance to nearest: Wetl Foundation " Property.Line _ - ,. i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I-) Depth I Size ` Number i SUMPS L] Distance to nearest: Well ?' Foundation Property Line DISPOSAL PONDS ❑ a i 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 f rules and regulations of the San Joaquin Local Health Di?trict. ' a ! Home owner or licensed agent's signature certifies the following:9 9 - g: "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•, i 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 require ons. Complete drawing on yreyame side. Signed Title: '� 1 �'� Date: ` f i FOR DEPARTMENT USE NLY f Application Accepted by Date Area r Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Ae ❑ 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.Q. Box 2009, Stk., CA 95201FEE a INFO AMOUNT DUE I AMOUNT REMITTED CAS RECEIVED BY DATE PERMiT'NO. :i +•EH13-241REV.r/x51 EH 14-26