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ie+ APPLICATION FOR PERMIT r �„ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .SI�GrJ(,er 7 — City Lot Size PM Owner's NameZ_?� Address go e Phon�6/1 — r � G1 Phon9� �� Contractor _ Address ..� '� r License No III` TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOVNDATION AGRICULTURE WELL.-_ OT TS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications i'i Public ❑ Other Delta Depth of Grout Seal Type of Grout I I Irrigationt�.Approx. pth l 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type ump H.P. State Work Done Well Destruction ❑ - ell Diameter Sealing Material (top 50') Depg '. Filler Material-Melow 5071- TYPE OF SEPI C WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTIO (No septic system permitted if public sewer is vailable within 200 feet.) 1 1 Installation will serve: Residence_ 'C-cmmercial M1_ Other Number of living units: Number of bedrooms ` a i Water table depth Character of soil to a depth of 3 feet: SEPIt-IC.TANK - X Type/Mfg Capacity No. Compartments I PKG.=TREATMENT PLT. ❑` Method of Disposal Distance to nearest: 1 Well Foundation Property Line LEACHING`LINE ❑, No. & Length of lines, I I Total length/size f FILTER BED ❑; Distance to nearest: s Well Foundatioh Property,Line I I SEEPAGE PITS I I' Depth Size V Number SUMPS ❑'. Distance to nearest: j Well Foundation Property Line DISPOSAL PONDS ❑� 1 z ! 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 thekSan Joaquin Local Health District. 1 I 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 taws of California." Contractors hiring or sub-contracting signature I 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." t The applicant st call for all required inspections. Complete drawingonon ruse side, / Signed X Title: Date: / y FOR DEPARTMENT USE ONLY 4 Application Accepted by �`�'� � Date — Area Pit or Grout Inspection ate �`� Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mente a 823-7104 ❑ Tracy 835 ! Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F 4 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED? RY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.I/H5) +� �V� EH 14-28 d✓`� ri