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APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.:HAZELTON AVE., STOCKTON, CA ti� 1i3 �w• Telephone (209) 466-6781 R . PERMIT EXPIRES 1.YEAR FROM DATE ISSUED (Complete 1n Triplicate) i 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. h I G Job Address �" p .9 I �t� City "-�`- Lot Size PM Owner's Name e1 MA A✓i212L5 Address Phone (o Z— g 5 A. 1 / �. Contractor's Name R A. Pmwi-eh j J 0141fLicense No. 7- V ill 411; Phone Z14 b ��D7 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 AGRICUVrURE WELL OTHER WELL PITS/SUMPS i i. INTENDED USE TYPE OF WELL PROBLEY ARVA CONSTRUCTION SPECIFICATIONS yy,_ ❑ Industrial ❑ Open Bottom VD Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications ❑ Public ❑ Other Depth of Grout Seal Type of Grout❑ Irrigation —Approx. Depth Surface Seal Installed by `n Repair Work Done ❑ Type of Pump H.P. State Work Done �1 Well Destruction ❑ Well Diameter Sealing Material (top 501 \ { Depth Filler Material (Below 501 w�1 TYPE OF SEPTIC WORK: NEW INSTALLATIONQ' I-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 Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 1 "" [ Total length/size FILTER BED ❑ Distance to nearest: -- Well i. Fou do atibn' Property Line SEEPAGE PITS ❑ Depth Size -Number---- SUMPS ❑ Distance to nearest: - Well Foundation Property Line DISPOSAL PONDS ❑ I' `' t • 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 hat.in�the.performance.of the Lork 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."Contractors hiring or subcontracting 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 all forallrequired inspections. Complete-drawing on reverse side. .._ Signed L � �rs� Title: Date: 2 F�EPARTMENTSE ONLYmmApplication Accepted by Cii.v _�� "Date P Area Pit or Grout Inspection by Date final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 -❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE rPPEERMIT"N0. +EH 1324{REV.10/831 y EH 14-26 U !