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ti { i e I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE.,.STOCKTON, CA y Telephone (209) 466-6781 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 3Q ' CJ {�1 C�"\ City \ Lot Size�o�^ r� Owner's Name N ""�5 �dt� ddress �Zl� �S �y Phone �� ; ContractorT +`�O�{Vg1 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑IT,racy" !' Type of Casing Specifications = ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation ---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 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-x Commercial i' Other Number oof living units: ,N bel of bedrooms�_— i + Character of soil.to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 00 SN No. Compartments PKG. TREATMENT PLT.-D-' 6 U Method of Disposal R � Distance to nearest: Well Foundation U Property Line LEACHING LINE '- ❑ No. & Length of lines 2 Total length/size FILTER BED , ❑ Distance to nearest:' FWell Foundation--^'— ,-^-�^Property-Line SEEPAGE PITS C] -pt 2 Size �� T ZZ - Number Z SUMPS ❑ Distance to nearest: Well �U F`r oundatron Property Line DISPOSAL PONDS ❑ 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 District- r ,. 4 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 eq ired inspections. Complete drawing on reverse side.. _ Signed X Tifle: Date: FOR-DEPARTMENT USE ONLY AAPlicatitSn Acce ted by - T� D t ' 1 Area - Pit—or,'Grout Inspection by Date "Final Inspection by Date Additional Comments: C] Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 a- O)Tr c '83r-6385 ? ': I Applicant- Return all copies to: Environmental Health ef�mit/Services 1601 E. azeltori Ave.,P.O. Box 2009 Stk., CA 95201IT . FEE -r AMOUNT DUE.—.. ^AMOLjNT REtd1ITTED ASHD RECEIVED BYT' —DATE--'' PERAAIT NO. ` " + EH t3-24{REV.i/a slINFO " S - 0, �� a EH 14-28 r