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i APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT } tt 1601 E. HAZE T ON AVE., STOCKTON, CA 1 ; 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ezlo l .S. 44-,2;_5 IQ ."- City Lot Size PM Owner's Name /£ .✓ C # Address Phone 7—` z Contractor _Address License No. Phone TYPE OF WELLIPUMP: lt NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. r ` I 1 Irrigation _Approx. Depth ! I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth � � • Filler Material (Below 501 �X TYPE OF SEPTIC WORK: .NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence Commercial-_ Other r Number of living units: Number of bedrooms Ci Character of sail to a depth of 3 feet: 'Water table depth SEPTIC TANK ❑ Type/Mfg apacity No. Compartments a F PKG. TREATMENT PLT. ❑ Method of Disposal Distan arest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length)siz`e` FILTER BED0 Distance to nearest: Well Foundation Property Line pEPAG ITS E I Depth Size _ Number SUMP ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 manriar 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, t shall employ persons subject to workman's compensa- tion laws of California." + The applicant must II for all required inspecti ns. 9o plate drawing on reverse side. Signed Title: le-r-11Date: FOR DEPARTMENT USE ONLY i Application Accepted by U11:3� _ Date Area i Pit or Grout Inspection by Date Final Inspection by u� +f e Date Additional Comments: lAk C�n Pat LL-aA .(( i&g19'X"I,_,- _('I11,UL�.1.4- ❑ Stk 456-6781 ❑ Lodi 369-3621 0 ❑ Manta a 1323-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 8H RECEIVED BY DATE PERMIT'NO. ♦ EH13-241REV.i/M5) EH 1 4-28 �J''�' •C-+� % /�� C�"' -�`(�