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t APPLICATION FOR PERMIT L`3 SAN JOAQUIN LOCAL HEALTH DISTRICTlyz QJ 1601 E. HAZELTON AVE., STOCKTON, CA o� Telephone (209) 466-5781 SAN �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LT QUJ A A OCA (Complete in Triplicate) 2(Z— 0�orH 11 TR C Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereln 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 z' _sa w /7`A1. AJ, 9–/ Ko, • — City Lot Size PM Owner's Name , Address 'Xti 7 Phone Contractor's Name �� License No. 63 ��J�- Phone TYPE CIF WELL/PUMP: NEW WELL IY WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ ZJdJ ,e L SEWER LINES DISPOSAL FLD. /)d�,.� FOUNDATION �us�JPROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS C3 " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 111� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 250 ❑ Irrigation — Type of Gr t CN ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 feet.) 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. & Length of lines Totaliength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS Property Line 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 District. 2 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." The applicant ust call for all r uire spections. Complete drawing o rave se s' s Signed X r Title: Date: FOR DEPAR ENT USE ONLY Application Accepted by �y Date '� Area Pit or Grout Inspection by Date /" A Final Inspection by Date 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 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. +EH 13-24 IREV.101881 EH 1yM `�O� � 4-26 1 C-1 1 ��f 1 O`$ '�1J 44