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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZE T ON AVE., STOCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .-4 ` .. �.. (Carnplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the Aoker inescnbe . This a'p ation 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. N Jab Address I --�� •. �L.�dI.SL• Pr' ' Jj�� . x' . ; " T� /V Lot� ,+ �' City sSize PM Owner's NamedC Address /1/ �vr' ./V t,��5 aY .rL _. " y Phone VA Contractor Address r License.No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESi `' DISPOSAL FLD. PROP-'LINE J— FOUNDATION AGRICULTURE WELL s OTHER,_WEtL_7:::= PITS/SUMPS ~ INTENDED USE TYPE OF WELL PROBLEM AREA CONS1!RUCT�PECIFICATIONS ❑ Industrial ❑ Open Bottom '- ❑ Mantecaa of-WeIlrEzcavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ❑Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation rox. Depth ❑ Eastern Surface Seal Installed by �q Repair Work Done ype of Pum i/✓ P H.P. State Work Done_ + Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth, Filler Material (Below 501 i TYPE OF SEPTIC WORK:- NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units; Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑" Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT- ❑ j Method of Disposal Distance to nearest: Well Foundation Property Line ; q j LEACHING LINE Ll No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: WellFoundation j Property Line ' i SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ Distance to nearest:" - Well Foundation Property Line DISPOSAL PONDS ❑ w. 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. 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 a licant must call for all re wired ins q pections- Complete drawing on reverse side. Signed C Title: LTA+�F�.Y 4/ 2` % 7 fi Date: F TMENT USE ONLY , Application Accepted by noL.,'l/{n��A6, .� Date Area Pit or Grout Inspection bDate Final Inspection byDate 9 � �* Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ a teca 823-7104 . ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED K INFO C RECEIVED BY DATE P7ERMIT NO. + EHf3.24SREY.1/r+51 ��-.vL7 'g'��()"(} 3b ` ` 74 _2��•1 { i (OG � EH 14-26 f V L -1 s,