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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F, 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Fj 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 'Z_ Job Address _ � f b. /�ICity Lot Size PM Owner's Name Fi?,f •._,— 1 Address MalWig JI�/ Phone ! Z�`' I Contractor P., OU--> Address 3 [ 910 rIgAflj t,., License No.61 Phone #A4- 0� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE • SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOU AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR REA CONSTRUCTION SPECIFICATIONS. } ..� ❑ Industrial ❑ Open Bottom ❑ Manteca cavation Dia. of Well Casing t ❑ Domestic/Private D Gravel Pack- El Trac Type o Specifications I'l Public f1 Other Delta Depth of Grout Type of Grout _ M 11 Irrigation __.Approx. pth i I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter + Sealing Material (top'50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I o septic system permitted if public sewer is c 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 i Distance to nearest: Well Foundation Property Line ,1 I LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line_ - SEEPAGE PITS i I Depth! x-Size - j` Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ rr I hereby certify that I have prepared this application anId that the work wilLbe done in accordance with San Joaquin county ordinances, state laws, and J 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 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-. mploy persons subject to workm`an's compensa- tion laws of California." The applicant must mall forall required inspections. Complete drawing on reverse side. Signed X Titre: - Date: 7 `3 FOR DEPARTMENT USE ONLY Application Accepted by � Date f � Area . r r Pit or Grout Inspection // Date Final Inspection by (T1Date Additional Comments: . e c-ft? � 11 e(r �-kf oti Q o vir.q,,, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ N anteca 823-7104 ❑ Tracy 835-6385 Applicant 'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFObMOUNT DUE AMOUNT`REMITTED_,' CASH RECECK 4 IVED BY DATE PERMITNO. y k , EH 3-24 IREV LTD EH 14-28 r