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APP%LICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA \ / Telephone (209) 4.66-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N-0 (Complete in Triplicate) /VQ 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 i 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 t Local Health District.' 4 Job Address < Y` .. F City Sfi w Lot Size S[?xLPM ! Owner's Name Address _. 's, i� r 104 y I c 1 1 G Phone d to b� Contractor &:E Address ^� C-f I TYPE OF WELL/PUMP: License No. I Phone 1 b NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP iNS TION ❑ SYSTEM REPAIR DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES � - DISPOSAL FLD, PROP. LINE FOUNDATION GRICULTURE W OTHER WELL INTENDED USEPITS/SUMPS TYPE OF WELL PROBLEM A NSTRUCTION SPECIFICATIONS ❑ lndustnaf & Open Bottom ❑ Manteca Ll Domestic/Private - C3 Gravel Pack Q Tra of Weli Excavation Dia. of Well Casing MPublic n Type Casing Other � elle Specifications Depth of Gr Seal I I Irrigation ` ' = _ _ Type of,Grout Repair Work Done EJ Type of Pum Approx. Dept IJ Eastern Surface Seal Insta by Well Destruction ❑ Well Di ter' I H P to Work Done_ I Sealing Materia! (top 50'I Depth - ( y!� Fi11er;Materia) IBelow 501 �fv TYPE OF SEPTIC WORK: NEW INSTALLATION 11- REPAIR/ADDITION i I DESTRUCTION IW No septic system permitted if public sewer is k Installation will serve: Residence '` Commercial— available within 200 feet.I i Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I I F SEPTIC TANK ❑ Type/Mfg Water table depth' � � � ' PKG. TREATMENT PLT. 1-1Capacity No. Compartments t Method of Disposal f Distance to'nearest: Well Foundation Property Line I LEACHING LINE of lines FILTER BED ❑ No. & Length Total length/size ❑ Distance toynearest: Well Foundation —_—L� Property Line r SEEPAGE PITS f'I Depth I Size SUMPS — Number t L� Distance to nearest: Well Foundation ' DISPOSAL PONDS ❑ } Property Line k I hereby certify that I have prepared this abplication 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 appiican must call for all required inspections. Complete drawing on reverse side. Signed Title: n W A-I e 'r [--D U_ S Date: I EPARTMENT USE ONtY Application Accepted by �� ' Date Area Pit or.Grout Inspection by. Date 1 Final Inspection-by _ Dated Additional Comments: � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 � Applicant- Return allCopiesto: Environmental Health Permit/Services 1601 E. Hazelton Ave., R.O. Box.2009, Stk., CA 85201 FEE AMOUNT DUE AMOUNT REMITTED K y \` INFO H RECEIVED BY DATE f3PERMIT•NO. { + FH 13-24(REV.ti51 EH 14-26 n