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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1.862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Slee C4 City! Lot Size PM Owner's Name EL I -A LC7"'0.1��Address Phone ` �— Contractor 11d V Addres,-µ. J(0 -l" License No Phone c TYPE OF WELL/PUMP:- NEW WELL ❑'I:- -� '._.JWELL REPLCEMENT;ID DESTRUCTION ❑� -PUMP INSTALLATION k-0 SYSTEM-REPAIR-,I� - u - OTHER-0 ----=- — -b s I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - -- DISP,,OSAL FLD. PROP. LINE - -= FOUNDATION AGRICULTURE WELLS r OTHER WELL�� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public � 1_1 Other � f 1 Delta Depth of Grout Seal Type of Grout _. I I Irrigation -Approx 1Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump -� H.P. � State Work Done_ f A Well#Destruction ❑ Well Diameter '1 Sealing Material (top 50 \V m - Depth.----I_��i + _ .._._Eiller Material (Below501 _ �l TYPE OF SEPTIC WORK: NEW INSTALLATION lit REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 1 r.fff 4F�t .� t`flex available within 200 feet.) 10 Installation will serve: Residence_ornmercial Other J Number of living units: Number of bedrooms rt ` Character of soil to a depth of 3 feet..� Water table depth lti k SEPTIC TANK ❑ Type/Mfg Capacity 'No. Compartments # PKG. TREATMENTjPLT. ❑ Method of Disposal Distance to nearest: Well - Foundation - Property Line - - - --- ------ i LEACHING LINE ! Cl No. & Length of lines 1 Total length/size FILTER BED EE ❑ Distance to nearest: Well I Foundation Property Line # 4 SEEPAGE PITS I I Depth Size Number SUMPS Y ❑ Distance to nearest: Well Foundation Property Line DISPOSAL- PONDS ❑ 1 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 Home owner or licensed agent's signature.certifies the follortiing:.F'I certify that in the performance of the work for which this permit is issued, I shall not ` employ any per n such'manner as to become subiect'-4o°workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the.fol win : "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 o ifo ( # The applic t st call for all raqu re inspect; n Complete drawing on raver a side. Signed X f Titla: Date: r 213 i FOR P&ARTMENT USE ONLY Application Accepted by Date Y d Area 02 � Pit or Grout Inspection by I Date f Final Inspection by Date Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy -835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 CK FEE INFO AMOUNT DUE �' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r.EH 13-24(REV.I/K 5) 3 �C EH 14-28 t ` 1 1+---