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APPLICATION FOR PERMIT L� SAN JOAQUIN LOCAL HEALTH DISTRICT NO Ways 1601 E. HAZELTON AVE.,,.STOCKTON, CA 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`" t Ir Job Address 19 Cit .:LotSize -M " Owner' Name "\ � lJ.t�„?d_n��( Address Contractor Address -31 License No. Phone' j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _L FOUNDATION AGRICULTURE WELL OTHER WELL MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP NS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Di xcavation Dia_ of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ., pprox. Depth. ❑ Eastern Surface Seal Installed by-- Repair Work D Type of Pump H.P. State Work Done_ S Well uction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ' DESTRUCTION (No septic system permitted if public sewer is r vailable within 200 feet.► i Installation will serve: Residence_ Commercial_ Other f Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: .- - Water table depth S i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments W LT. ❑ PKG. TREATMENT P "" 1 ! f € R f t Method of Disposal U" ' Dista ce to ntearest, Well Foundation Property Line I LEACHING LINE L1Nor& i ength of lines Total length/size FILTER BED ❑ -Distance to nearest: � Well Foundation Property Line I SEEPAGE PITS } ❑ Depth Size Number SUMPS ❑., Distance to nearest: Well 'W-w -- -Foundation-Property perry Line DISPOSAL PONDS ❑ 1 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. 4 y Horne 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 must call for all required ins actions. Complete drawing on reverse side. x Signed X Title:: Date: 3 O^�-7 FO D PARTiUIENT USE ONLY Application Accepted by OC4" Date Lt 3 v~ Area Pit or Grout Inspection by Date Final Inspecctiioo by Date Additional Comments:/ ;7/ l/ G-"(C�� ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 . - .❑ 835-&385Tracy 835- 85 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE ' AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. f _ EH 13-24 �500 EH 44.28 fREV.t/x51 r