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APPLICATION FOR PERMIT x: �y I/ SAN JOAQUIN LOCAL HEALTH DISTRICT C 1601 E. HAZEL T ON AVE., STOCKTON, CA S Telephone (209) 466-6781 PERMIT EXPIRES TY EAR 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. Job Address A I_ City, 7 Lot Size PM Owner's Name ress Pho-6(613 �1 Contractor Address ty �1� L License Phone '�J¢ TYPE OF WELL/PUMP:. _ NEW WELL ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Man Dia.-of Well-Excavation - Dia. of Well Casing ❑ Domestic/Private ❑.Gravel Pack racy Type of Casing Specifications [-I Public ❑ Other. n Delta Depth of Grout Seal Type of Grout I I irrigation pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destructi ❑ Well Diameter Sealing Material (top 50'), Depth Filler Material (Below 501 ` 91-S\ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1REPAIRIADDITION I OESTRUCTIO M. septic system permitted if public sewer is 1-S available within 200 feet.) Installation will serve: Residence— CommercialOther' N Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _ �/r SEPTIC TANK ❑ Type/Mfg _..__ Capacity No. Compartments PKG.,TREATMENT PLT. ❑ Method of Disposal ,4 Distance to nearest: Well Foundation ."Property Line l t � LEACHING LINEj ❑ No. & Length of lines --.Total-IengtA/size FILTER BED tf ❑ Distance to nearest: Well Foundation ` Property Line . + SEEPAGE PITS 11 Depth Size _ Number SUMPS ❑ Distance to•nearest: r 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 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 California." # The applicant ust call for all requir'e spections. Complete drawing on to se side. / 7 Signed X i Title: Date: 7- j1� T 1]� / FOR DEPARTMENT USE ONLY Application Accepted by fi��ti „-„` R a� T Date l ” Ar Pit or Grout Inspection by Date ' Final Inspection by Date Additional Comments: L-r '. ❑ 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 FEE. INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH14-24iFEV.FiN51 EH 1 y