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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT `,)F—L /l 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)-466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ] a (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` ' -l-t� f' . 2514 •, City 511�Iev Lot Size PM � Job Address z —� �.. - Owner's Name iGv1ress _�� l Phone Contractor Address - License No. Phone F 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 A ULTURE WELL OT LL— INTENDED INTENDED USE TYPE OF WELL t PROBLEM AREA T SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of ccavation Dia. of Well Casing ❑ Domestic/Private '❑ Gravel Pack ❑ Tra Type of Casing-1--l- Specifications ❑ Public '❑ Other Delta _ Depthlof Grout Seal Type of Grout Ll irrigation �ppro pth ❑ Eastern Surface Seal Installed by j Repair Work Done -❑ Type ump H.P. f State Work D t Well Destruction ❑ ell Diameter Sealing Material (top 501 Depth y :y''` Filler Material /Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other i Number of living units: Number of bedrooms Q L Character of.soil-.to a depth of.3.feet:_. -- -4,----- 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 a No. &Length of lines i Total length/size FILTER BED ❑ Distance to-nearest:""` Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth Size' Number SUMPS ❑ 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, state laws, and rules and regulations of the San Joaquin Local Health District. t 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 The a scant must c II for all required inspections. l awing on reverse side. Signed Title: ! G./i�.��------. - Date: �+� � n- FOR MENT USE ONLY 1 `V�+�. Date � oil aI�R Area Application Accepted by k � � k Pit or Grout inspection by Date Final Inspection by Date I I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 835-F 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 RECEIVED BY DATE PERMIT''N0. ' INFO I Ud + EH 13-24/REV.s i a 5) EH W26