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$ APPLICATION FORIP.ERMIT 1� � SAN JOAQUIN LOCAL HEALTH DISTRICT ��r g� �� J L3 1601 E. HAZELION AVE., STOCKTON, CA g� �w C� L,)� worK� F N JOAQUIN LOCAL Telephone (209) 466-081 C `''HEAL T H DISTRICT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �zU r 25 o �� I {Complete in Triplicate} Application is hereby made to tl a 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 _fG'-+��• _ City �--.1 Lot Size PM Owner's Name �p�—2�� Address Phone -7403 I J i Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION E] SYSTEM REPAIR ❑ OTHER G _ 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 C ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type"of Pump �.A-+� H.P. lAr Well Destruction ❑ Well Diameter Sealing Material {top 56'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i I SEEPAGE PITS ❑ Depth Size Number SUMPS •❑ Distan a toynearest: 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-Sa Joaquin Local Health District. Home owner or licensed`adenYs signature ce'rtifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not employany 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." 11 The applict must call forA required inspections. Complete drawing on r se side. r Signed g Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by'k'�k's " i�^ Date 2 Area if Pit or Grout Inspection by Date Final Inspection by_bV Y_x i njn� Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 k Applicant- Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTER I �yCK 0/ F{ RECEIVED BY DATE PERMIT`NO. +EH13-24(REV.101831 + ... � 13.1 I b .� "T�^�t� g1,•� EH 1428 �l [ [