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t APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4 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. Job Address v2 '� City of Size PM Owner's Name Address %41 L�Ce� Phone Contractor � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEST UCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE L. OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS }t - ❑ Industrial ❑ Open Bottom ❑ Monte Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr y Type of Casing Specifications ('1 Public ❑ Other Delta Depth of Grout Seal Type of Grout 1 1 litigation —._Approxi Da I 1 Eastern Surface Seal Installed by � - I Repair Work Done ❑ Type of Pump H.-P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 + t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION 11 DESTRUCTION l (No 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 No. Compartments PKG. TREATMENT PLT. ❑ { Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Leri th of lines i g ,Notal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth ' Size Number SUMPS L-] Distance to nearest: Well 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, stale 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 fallowing: "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." 3 The applicant m calf for all required inspections. Complete drawing on reverse side. r� Signed X� Title: -- Date: FOR DEPARTMENT USE ONLY Application Accepted by 1C_m Date 1 Area Pit or Grout Inspection by + Date Final Inspection by �t Datef_ A itional Comments: �2 —! 7 1Stk 466.6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 5 5 — f Applicant- Return all copies to: Environrilental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFOkAMOUNT DUE r AMOUNT REMITTED C RECEIVED BY DATE PERMIT N0. + EH 14-21 IREV.i i x sl -' _`7��'►^_�� "��`� - EH 14-2a • - r