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APPLICATION FOR PERMIT IN 40 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a 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 andthe Rules and Regulations of the San Joaquin Local Health District. r Job Address Ali 1lr e.c tat4A tO KI& l d 'City � r ��ot Size PM I J ' r j J ��t c11 etit K 5 f Owner's Name `e ��r Ct { Address Z-0S8a SQ 5 w0 V Phone —45p?-, Contractor f "►�-t f/I.F�.f- v-- Aii&es's Rol_& Q , /YIDeq _License No. Phone29tol t�TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES ' ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom t,�.f�'Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private El.Gravel_Pack ❑ Tr Type of Casing Specifications ❑ Public _. ❑ Otherr�----�- elta�'" Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Dep ❑ Eastern Surface Seal Installed by Repair Work.Done ❑ Type of Pum H.P. State Work Done_ Well Destruction ❑ Well.Dia er' Sealing Material (top 50',1., n Depth' `" i . Filler Material (Below 501 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 ��\ t Number of living units: Number of bedrooms r F Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mf '. 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line rSEEPAGE PITS ❑ Depth Size."`' 1 Number .SUMPS, ❑ Distance to nearest: 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 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, ►,shall not ,f employ any person in such manner as to become subject to workman,.compensation laws of California." Contractor's hiring or sub-contracting signature '"certifies twe 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- -6ion laws of California. - The applicant mut call for alFrequired in' actions. Complete drawing on reverse side. Signed X Titre: / _Date: f__ 1 r FOR.,DEPARTMENT USE ONLY Application`Accepted by Date _ Area t Pit or Grout Inspection by Date Final Inspection by Dafe 7 Additional Comments:_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy. 835-638 ' Applicant Return all copies to; Environmental.Health Permit/Services 1601`E. Haielto'n Ave P.O. Box 2. W9, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ac+ EH 13-24(REV:iiHsl EH 14-20