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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 4666.6781 1,J1 EA- PERMIT APERMIT EXPIRES TYEAR FROM DATE ISSUED {Complete in Triplicate} a�w4 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. a �!, Job Address i7 L_ IZ ,04? tS City of Size PM Owner's Name�:-„�/� Ste/ A—� Address Phone Contractor�;ttf l Sr1+.W a ddress —�141 1,0A7R7WILZe No. Phone 361 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE W41- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO LE REA CON RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack El Tracy a of Casing Specifications' n f'l Public ❑ Other Ll Delta epth Grout Seal Type of Grout "Y`1 I I litigation Approx- Depth I I Eastern Surface Sea tailed by _ Repair Work Done ❑ Type of Pump H R State Work Done_ Ow Well Destruction 0 Well Diameter Sealing Material Stop 501 Depth Fjlier Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l I DESTRUCTION Mom septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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, (shall not employ any person in such manner as to become sqbject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfor nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la California." The applica t mus all for all req s. Complete drawing on reverse side. �J Signed X Title: Date: n 1 FOR DEPARTMENT USE ONLY Q Application Accepted by �it1J nom_. 1{4. _ A [ � o.r.,-U Date 1 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-71D4 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOOUUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. + EH13.24IHEV,t/x55 �jI I 6V / .-�M EH 14-28 g/