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APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466=6781 PERMIT EXPIRES TYEAR 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.. 1 Job Address / LY �� CO#c,�-a s 1 City Lot Size a -- PM Owner's Name Address �/' �/_sz Phoney Contractor - -�4 r� __ ._ Address - O a License No. Phone .TYPE OF WELL/PUMP: NEW WELL ❑ „WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL-TION ❑ SY TEM,REPAIR ❑ " ^x, OTHER ❑ DISTANCE TO NEAREST:"SEPTIC TAO - - SEWER LINES,. 'bISPOSAL-FLD. --- -- -PROP. LINE FOUNDATION 'r AGRICULTU L OTHER.WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL OBL EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom nteca Dia. of Well Excavation rte. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tra Type of Casing . Specifications l'l Public ❑ 0th ❑ Delta Depth of Grout SeaK Type of Grout _ t ., I I litigation __Approx. Depthk�l ] Eastern Y Surface'Seal Installedlby i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 50'] � .-,..�. rte-•-e �—,;..�.-. �.. .,Depth 'Filler Materi,�:al- (Barlow 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADbiTION I DESTRUCTIO (No septic system permitted if public sewer is F available.within 200 feet.) Installation will serve: Residence_ °Commercial Number of living units: Number dbedrooms i t r {{ 1 Character of soil to a depth of 3 feet t Ei ` Water table depth SEPTIC TANK ❑ Type/Mfg :Capacity ( No. Compartments PKG. TREATMENT PLT. ❑'� _ t -: ! Method of Disposal: .Distance to nearest: Well Foundatiari Property Line LEACHING LINE ❑ No. & Length-of,iries k Total length/size- FILTER BED ❑ Distance to nearest: f Well Foundation f Property Line } SEEPAGE PITS I i Depth Size _ Number I SUMPS ❑ Distance to nearest:' Well Foundation � " j Property Line. f DISPOSAL PONDS ❑ kI 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:-----_ _ 9 1 i -11 Home owner or licensed agent's signature certifies the following:."I certify that inyl}ta•.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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required ins tions..Complete.drawing on reverses. Y � Signed XV—j r��l/L Title: y Date: - :z-- FOR--DEPARTMENT_USE-ON /f ' t�:— Application Accepted by ? Date r/a Ak' � Area Pit or Grout Inspection by Date .Final Inspection by Date 2 E Additional Comments: } ❑ Stk 466-6781 ❑ Lodi _36A621 ❑ Manteca W-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'flox 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED I I RECEIVED BY J DATE PERMII'NO. INFO C ' + EH 13-241REV.iin51 EH 19.26