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i. n APPLICATION FOR PERMIT 4SAN JOAQUIN LOCAL HEALTH DISTRICTS 1601 E. HAZE T ON AVE., STOCKTON, CA O Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED No � 1. (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. t t ; Y .fob Address ., City Lot Size PM Owner's Name 7Pn b - Address `' ' Q [1 }= f` Rte/►v -_ Phone�x 1 Contractor G. Address License No. Ph on TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f►'"� ❑ Industrial ❑ Open Bottom c )Q!iJhKtt]J Dia. of Well Casing❑ DomesticlPrivate ❑ Gravel Pack R+ ❑ r�k iT T Specifications y l"f Public ❑ Other (�n Delta y, Deppthh of�rGpr(�t � I F � Type of Grout _ I t Irrigation Approxi Depth rlli MIMay havaggpitR - _ Repair Work Done ❑ Type of Pum y, Work Done p YP �p ��a'� � - �� ' E Well Destruction ❑ Well Diametfr '+ �� ealing IVIG ri Depth 7 �' �71a1 � TYPE OF SEPTIC WORK: NEW INSTALLATION i l REP A R/ADDITION I I DESTRUCTION (No sepKc system permitted if public sewer is avail a within 200 feet.) i Installation will serve: Residence _ Commercial_ er Number of living units: Number of bedrooms f �a.-. �� +� Character of soil to a depth of-3 feet: f tofeepth SEPTIC TANK ❑ Type/Mfg Capacity ments PKG. TREATMENT PLT. ❑ tilE E)( jr�d to f ethnod of Disposal Distance to nearest: Well work @�D'•fnr n Prgperty Lpgf . for in LEACHING LINE ❑ No. & Length of lines d +t✓ fFi ��si3 I 01U11 I FILTER BED ❑ Distance lo nearest: Well Foundation Property Line " 1 SEEPAGE PITS ( I Depth Size Nu bar , SUMPS ❑ Distance to ne rest: Well Foundation. Property Line DISPOSAL PONDS ❑ I 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, 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 applicant must c II f all requir spections, CompI drawing on reverse side. Signed - Title: Date: R DEPARTMENT USE ONLY r f q I r� Application Accepted by ► Date b'r �~ [ [ Area ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE INFO AMOUNT DUES AMOUNT REMITTED CA$µ 11 RECEIVED BY DATE PERMIT NO. a EH 13-241REv.i/H51 • �EH t4-28 i ! Sf V yr`wl 1 1