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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ONxAVE, STOCKTON, CA Telephone (209)-466-6781 PERMIT EXPIRES 1"YEAR'!FROM,DATE 'ISSUED'' " ` #' •' i (Complete in Triplicate) M.' C �r ib.�lf tlt . r . � :i =.:to aflcry:'L� _f',' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.t,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. s4 �i ,,, Job Address } �( -` z City� � Lot Size PM i i,:r t Owner's Name e _1'` Address -- - Phone I Contractor Lv7,e, dress © 22 L1 C, L icense Nva i51 T C hone 'TYPE`OF WELL/PUMP:— NEW V4IELL❑ WELL:`REPLACEMENT L7µ' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR EJOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE_OF_WELL,.. ..'-PR0BLEMAREA,-..CONSTRUCTION SPECIFICATIONS- l ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia:of Well Excavation .r-&a.-6f Weli Casirig`� ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casin g Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation Type of Grout 9 ---Approx. Depth ❑ Eastern Surface Seal Installed by ,;;,,�, i Repair Work Done ❑ Type of Pump iti . Fl.p�" ";'. �— --.�— State Work Done r, Well Destruction ❑ Well Diameter s Sealing Material (top 50') 4 V Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LN- EMSTRUCTION ❑ (No septic system permitted if public sewer is . .' �"` / : r available within 200 feet.) J x Installation will serve: Rest ence commercial_ the V i Number of living units:� Number of bedrooms .Character of soil to a depth of 3 feet: r r° } Water table depth SEPTIC TANK ❑ T e/Mf t t Type/Mfg g Capacity No. Compartments r i PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Weld.,` Foundation Property Line LEACHING LINE No. & Length of lines Total length/size '` 1 FILTER BED" -Distance to nearest: Well Foundation Property Line "��. SEEPAGE PITS ti—mepth Size Numbe SUMPS ❑ Distance to nearest; Well i Fount ion f" i Property Line DISPOSAL PONDS ❑ r ( i k ;,rtei + hereby certify that I have prepared this application and;thaf theywork will be done in accordance with.San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t I Home owner or licensed agent's signature certifies the following. "•work f employ an '�'•I,fce{tify that in performance_of the work for<which this permit is issued, I shall not p y y person in such manner as to become subject td workman's compensation laws of California.'"Contractor's hiring or sub-contracting signature cert"' the following: "I certify that in the rformance of the work for which this permit is issued;�I shall em io tion la f California.' 6 i p p Y persons subject to workman's compensa The applican us call or II re fired pectin Co late drawing on r arse side, t Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l Area Pit or Grout Inspection by ateinalI Inspection by ate Additional Comments: ❑ Stk 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT'NO. +EH 13-24{REV. /a r)) - EH 1126