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APPLICATION FOR PERMIT �- SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZEL T ON AVE.,,STOCKTON, CA Telephone (209) 466-67$1 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. Job Address =7: - F City Lot Size PM Owner's Name l_ r 1 0, � Address � ��P r t 1/.-_ I J Phone l� � Contractor Address License No. Phone r TYPE OF W LI UMP: WIN WELL WELL REPLACEMENT El DESTRUCTION ❑ LATION/❑ PUMP INSTALSYSTEM REPAIR ❑ OTHEF ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD... �(�PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL �� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom antece Dia..of Well Excavatio q�1 1 h~ Dia. of Well Casing pmestic/Private Cl ravel Pack Zflacy Type of Casing 1 ! Specifications C/ P��L ublic i�J Other ❑ Delta Depth of Grout Seal Type of Grout \� ❑ Irrigation q--&Approx. Depth ❑ Eastern Surface Seal installed by � �! RePair Work Donee ❑ Type of Pump H.P. State Work Dolle Well Destruction CI ;Well Diameter Sealing Material (top 50'I � :Depth 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: ResidenceCommercial_ Other Number of living ur)jts: .. _.Number;of bedronms� Charactqr of soil to a.depth of 3 feet- Water table depth f SEPTIC.TANK ❑ T /Mf.. i ype g'`- Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ize Number SUMPS F1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 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 m ll for all req ire inspections. Complete drawing on reverse side. Signed X Title: Date: r` FOR DEPARTMENT USE ONLY s Application Accepted by- Date " Area E C__` _ Pit or Grout Inspection by / Date Final Inspection by Date Additional Comments: / �, J I •J L <9 �� I ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 I (, { FEEAMOUNT Dili: AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. a: INFO CASH . EH13.24IREv.I/851 ` EH 14-20 r i i