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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 hetehy 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. Lec'M�v Job Address QC1Lz�i C CZ" Cit Lot Size�+L�X f0 of S� PM Owner's Nam Address-M.75 f!fl• _ Phone —�q Contractt,4 , , COAddress p(J.L7[J/� '7(g Z&i [&& License No. Y� Phone 1_- 16 �l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE G, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL . .PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications P Public Cl Other Cl Delta Depth of Grout Seal Type of Grout ---- I i Irrigation _,Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence r Commercial_ ther . / M Number of living units: __L Number of d oms Character of soil to a depth of 3 feet: _ '' Water table depth SEPTIC TANK Type/Mfg c r Capacity No. Compartments PKG. TREATMENT PLT- ❑ r Method of Di osal sp Distance to nearest: Well �'� Foundation _/� � Property Line -� 7 _ LEACHING LINE No. & Length of lines I L46` --TppI length/size X� _ FILTER BED ❑ Distance to nearest: Well--15v _--_ .Foundation - Property Line - i .. . . . d in SEEPAGE PITS X Depth Size Number - SUMPS Ll Distance to nearest: Well 1, Foundation—1AQ e 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: 1 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 st call for requi d inspections. Complete drawing on reverse 'd b 07 1 Signed X Title: v, - Date: f / FOR DEPART ME T USE ONLY Q. T Application Accepted by Date ��' G C� Area l Poor Grout Inspection by ate p Final Inspection by Dater-_3 � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CI 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 INFO AMOUNT DUE AMOUNT REMITTED CASH49 RECEIVED BY DATE PERMIT'NO. +.EH13-24(REV. �J ryVEH 1 _�flf