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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) " u w 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. i Job Address#_ s� �� [AVIV _'.Cit ✓,� _ - Y Lot Size PM .. Owner's Name /`rLIZs.Zd4z"Z/:r,[V'iC.._i Address -36�40,d=) L Phone I Contractor - Address ;cense No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ I I OTHER ❑ C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES bAPUiAL FLD. ! PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL ~1 PITS/SUMPS INTENDED USE j TYPE OF WELL PROBLEM ARE NSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation 6 Dia. of Well.Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications .r El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done n Type of Pump H.P. State Work Done_ I Well Destruction Q Well Diameter Sealing Material Itop 50'i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LIREPAIR/ADDITION DESTRUCTION El (No septic system permitted if public sewer is . available within 200 feet.) Installation will serve: Residence— Commercials Other - Number of living units: Number of bedrooms 1—_ � h Character of soil tota depth of 3 feet: IWater table depth V SEPTIC TANK ❑ Type/Mfg 1 Capacity � No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal k Distance to nearest: Well I Foun(dation Property Line FILTER BED �❑ u Distance to nearest: Well F ; s LEACHING LINE No_ & Length of)tries —.. �� t d� Total length/size .©� Foundation �.�-�r property Line�� � r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! 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. Home owner or licensed agent's signature certifies the following: "1 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 must call for all required inspections. Complete drawing on reverse side. .w Signed � Title: ��....,. � .�.-».�....._......,.--�......�.�..,�.Y,_....�.. , Date: a FOR DEP TII14ENT.USE ONLY } ' ♦ - �� '.h.2 5-„J id. -�-�' Application Accepted by pate Area Pit or Grout Inspection by Date. F' nspecti oniby Date/ �Z 7 Additional Comments: t ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ M ntr M-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Heal ft'�i Pe t/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.i i n sl j }� _ ��■. 9-7 EH 14-28 Lf �IYf �y ^`l