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4`1 j APPLICATION FOR PERMIT -- li SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA s Telephone (209) 466-6781 E' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 Imade 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. it 'Job Address 0A City 1&& Lot Size PM H I :.Owner's Name ._..lStl + ,�-+� Address �"�( - Phone It i4Contractor Address License 13y Pfio TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ n _ 16ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL , OTHE PITS/SUMPS _ INTENDED USE TYPE OF WELL ' 'PROBL`EMAREA CONS SPECIFICATIONS Industrial ❑ Open Bottom ❑ Mantec Pia. of Well Excavation �^ µDia. of Well Casing n �i❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications E,[7 Public F1 Other Cl Delta Depth of Grout Seal Type of Grout _. G I I Irrigation ---Approx. Depth i I Eastern Surface Seal Installed by _ iiRepair Work Do Type of Pump H.P. State Work Done �Pell,Des tion ❑ Well Diameter Sealing Material (top 50')_ I. j: Depth —Sealing Material (Below 50') ` €`TYPE OF SEPTIC WORK: NEW INSTALLATION € I REPAIR/ADDITION I 1 DESTRUCTED INo septic system permitted if public sewer is �r available within 200 feet.) Ei installation will serve: Residence_ Commercial_ Other ii Number of living units: Number of bedrooms E Character of soil to a depth of 3 feet: —Water tab)e depth F tiSEPTIC TANK ❑ Type/Mfg ° Capacity— No. Compartments E`PKG. TREATMENT PLT. ❑ 4 4 Method of Disposal E! Distance to nearest: Well Foundation { Property Line i i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i` i"SEEPAGE PITS 11 Depth Size, Number "SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ rt +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. 't 71 I�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 manna(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- �Ition laws of California." The applicant ust call for all required inspections. Complete drawing on reyprse side. Signed X Title: Data: s .� FOR DEPARTMENT USE ONLY n 7 11 Application Accepted by Date G� T Area a � Pit or Grout Inspection by � Pate f=inal Inspection by Date / I'Additional Comments: a 161 f , 7�—lSo� _ ❑ Stk 466-6781 ❑ Lodi 369-36521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i. FEE N INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. r EH I.13-24(REV.1/n sl EH•11 a-28 CCCJJJ e