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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 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot SizePM ti Owner's Name Address K2,10 b(0 Phone W 2 Contractor ddress/ N,5_JL cense No. � Phone TYPE OF WELL/PUMP: NEW WELL © WELL PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION YSTEM REPAIR ❑ "� OTHER ❑ k, ' r j DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD, PROP. LINE } FOUNDATION AGRIC TURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBL EA CONSTRUCTION SPECIFICATIONS ✓ ❑ Industrial ❑ Open Bottom ❑ Mante ,,�.r,Dia.-of-Well.Excavation— Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications 1'1 Public ❑ Other ❑ D to Depth of Grout Seal Type of Grout I i Irrigation --Approx. Depth l I astern Surfacef Seal Installed by Repair Work Done ❑ Type of Pump / H.Pr r State Work Done Well Destruction ❑ Well Diameter Sealing aterial hop SO') Depth .._.Filler-Mate' -(Below-50-I_--�---- �_ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I D STRUCTIO No septic sy tem permitted it public sewer is /1 ova le wit n 200 feet.) V11- Installation will serve: Residence Commercial Other /�J Number of living units: Number of bedrooms If Character of soil to a depth of 3 feet: Water table depth P p SEPTIC TANK ❑ Type/Mfg `� Capacity Z No. Compartments PKG. TREATMENT PLT. ❑ t. ,A Method of Dis osa Distance to nearest:—Well "'^°"Foundation. l� Property Line # LEACHING LINE ❑ No. & Length of lines 'T9tal length/size FILTER BED ❑ Distance to nearest: Well Fo nation Property Line SEEPAGE PITS [ I Depth 2 Size 75A Pumber SUMPS L7 Distance to near st:"'""'"'rWelt Foundatio Property Line DISPOSAL PONDS ❑ 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 that in the performance of the work for which this permit is issued, I shall not I 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,1 shall employ persons subject to workman's compensa- tion laws of California."-,, The applicant must call for eg4ired 1 pections. Complete drawing on reverse side. I Signed X Title: fi—I `i _ Date: FOR DEPARTMENT USE ONLY Application''Accepted by Date 0 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. ;Bdx 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE _PERMIT'NO.. INFO .-CASH- EH -CASHob EH 14-24(REV.t/x 51 ✓ +�� O r EH 14-26