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k �a APPLICATION.FOR PERMIT f� v ` SAN JOAO,UIN•LOCAL HEALTH DISTRICT I L_ r 1641 E. HAZEL-i ON AVE., STOCKTON, CA •• � "'Telephone'(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.in Triplicate) r na 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 4 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 �" &* City Lot Size PM I t Owner's Name Ph �� K� i / P�--`'—� Address �' -- " on f Contractor � /�C�Addres�`�� E— License N6.9 �p Phone ■� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 0J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L7 VQ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSA LINE FOUNDATION . AGRICULTURE WELL HER WELL PITS/SUMPS �Y INTENDED USE TYPE OF WELL PROBLEM A NSTRUCTION SPECIFICATIONS ❑ Industrial Q Open Bottom eca Dia. of Well Excavation 6 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing Specifications ❑ Public er "' ' ❑ Delta Depth of Grout Seal i Type of Grout ❑ Irrigation �pprox. Depth Q"Eastern E Surface Seal Installed by Rep rk Done ❑ hype of Pump . . HP. State Work Done Well Destruction ❑ Well Diameter 'SS ealing Matelrial trop 501 + Depth Filler Material IBelow 50.1 ' TYPE OF SEPTIC WORK: `NEW INSTALLATION ❑ REPAIR/ADDITION L7 DESTRUCTION INo septic system permitted if public sewer is +� t available within 200 feet.) Installation will serve: Residence� Commercial-�a- �� Other F. Number of living units: Number of bedrooms Character of soil to a depth of 3-feet:.----------- -- --�-- f Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. LI ; Di . j Method of Disposal stance to nearest: Well Foundation 1 'Property Line LEACHING LINE O No. 8 Length of((Hess �r Total length/size FILTER BED ❑ Distance to nearest: Wv"Al h 4 f Foundation Property Line } SEEPAGE PITS ❑ Depth Size ( Number I SUMPS ❑ ..Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS ❑ I I hereby certify that I have piepared 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 District. 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." 9 I I The applicant st call for all to in ctions. Complete drawing on erse side. C r Signed X Title:' Date: f FOR DEPARTMENT USE ONLY I Application Accepted by Date �' � Area C� . 4 N Pit or Grout Inspection IDate _Final Inspeciion6y_ - Dat S Additional Comments: --Zl^ - f ❑ Stk 466-6761 '❑ Lodi 369-3 21 ❑ Manteca-823-.7/104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO :+ EH 13-241REV.1/551 - ��]U 5 •�� .. .{'30 EH 14.29 }