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APPLICATION FOR PERMIT SAN JOAQUiN LOCACHEALTH DISTRICT 1601 E. HAZELTOW AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED K � ' (Complete in Triplicate) "" `'' ` C• Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the4work'herein described. TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ and the Ryles and Regulations of the San Joaquin Local Health District. �yy t� , 4. / .� o�`�y� ..54-V26.5 p Job Address /tP / Y t ' �,� / t0 - i City' e,%IJ. Lot Size PM ' Owner's Name - - Address Phone '_..:.,"-Contractor Address_ PO, ) ,,. _sr� License YVo,~ if�Phone Y TYPE OF WELL 1:111'''11111111p: NEW WELL ❑ WELL REPLACEMENT ❑ M T PUMP INSTALLATION`❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ } OTHER ❑ SEWER LINES I r ' FOUNDATfON �-- DISPOSAL FLD. PROP. LINE PM AGRICULTURE WELL I S INTENDED USE USE OTHER WELL PiTS/SUMPS TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATION' S ` ❑ Industria! ❑ Open Bottom ❑ Manteca ❑ Domestic/Priya "Dia. of Well 9xcavation ! Private ❑ Dia. if Gravel Pack ❑ Trac Well Casing ❑ Public Y Type of Casing i l ❑)'Other ❑ Delta -" Specifications t Depth of Grout Seal ❑ irrigation !Approx. Depth ❑ Eastern TYAe of Grout ; Surface Seal installed by f Repair Work Done ❑ Type of Pump H.P.��-rte " , Well Destruction ❑ LNefl Diameter State Work Done , ! Sealing Material (top 50') 6 + i Dlpth f""•"Filler Material{gelow 50'► `�^^ TYPE OF SEPTIC WORK: NEW INSTALLATIONEPAiR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is_ _� l9galiation will serve: Residence Comrfierciaf available within 200 feet.) Other Number of living units -F ""Number of bedrooms" i� �- _ ._ Character of soil to a depth of-3 feet: SEPTiC TANK type/Mf i Water table depth 0 7 g Capacity PKG. TREATMENT PLT. ❑ ��- Na. Compartments ^� i Distance to nearest., ` rd � r Method of Disposal Well Found tiori. Property Line s Ll ACHIPI LINE ., -No. &Length of I es, ` T ' FILTER'BED --+Total IMgtEl~Fsize ! Distance to nearest:, Well f" ` t a - ) G �•- '",-- — --. _,Foundation' o�t� ;Property Line �F qr SEEPAGE PITS ❑ r'Depth•:,: Size ) SUMPS € Number ❑":Distance to nearest: Well I € r DISPOSAL PONDS' ❑,. _ _ Foundation Property Line • .•,,� l :rT :f:" I hereby certify that f have prepared this a`"lication and.thatthe work will be dDi�t ` rules and regulations of the San Joaquin Local-Health bistric't. f e in accordar]ce with Stan Joaquin cotihty ordin nces, state'1aws, and Home owner or licensed'agent's signature certifies'�the followin t I, Ev[ y + ". "•. °.j '& � emn the perform ploy any person in such manner as to become subject to wo kman's a compensation laws of Caiifom a." Dint actors srh.1 ppsub`contra ct ng sigrialturDie certifies the.toilowing:"I certify that in the performance of the work for which this,permit`isFissued,I shall em fo tro} laws of California." 1 p y persons•subject to workman's compensa- ,tµThe applicant must call r I requ'red inspections. Complete drawing on reverse side. 1 F µ t Signed < t Title: ��i Date: 3d— A5�1 i I FOR DEPARTMENT USE ONLY i Application Accepted bY'. € Date Area Pit or Grout Inspection by s f•. Date: Final Inspection by ,,.4;: ;p � r n i I t .fit Date Q -- • 1� ` - Additional Comrhents: } ❑ Stk 466-6787 - -^•,._,..,.• ._��,�,r . ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 Ap386 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., 0. Box 2009, Stk., CA 95201 ) k FEE INFO MOUNT DUE AMOUNT REMITTED CASH V RECEIVED BY / � DATE PERMIT•N0. ,+EH 1324 REv.1/e.51 L/!11P EH 14-26 �Yze mss- J-1 C.