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APPLICATION FOR PERMIT ® , SAN JOAQUIN LOCAL HEALTH DISTRICT '� 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe I 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 Na.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �- fC?�O�l City -�� Lot Size. PM G>0lJSY'f'L9�7741�T Q� C� Owner's Name - Address >/J Phone Contractor + ?WDA,/ -� Address �' �� License No. Phone / TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS INTENDED USE TYPE ., ELL- PROBLEMAREA.,._CONSTRUCTION.SP_ECIFICATIONS-_-� -r --- - =� - ❑ Industrial ?. ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public f l Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. f�- State Work Done SfJ r Well Destruction Ll Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION f I (No septic system permitted if public sewer is " uaifable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms f Character of soil to a depth of 31e Water table depth ii SEPTIC TANK _ ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal u Distance to WeareWell Foundation Property Line Lp .. LEACHING LINE ❑ No. & Length of line Total length/size FILTER BED L1 Distance to near t: Well ndation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS L] Distance to nearest: Well Foundation Property Line V `•� _ 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 LocallHealth'Di§trict. �+ i Home owner or licensed agent's signature certifies the following: "I certif'r.that:in the performahce 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 compensatibn 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 mu require s i,tions. Complete drawing on r rs side. r �7 Signed X Title: c� --Q „_,— Date: ' FOR D ARTMENT USE ONLY Application Accepted by Date - Area O i Pit or Grout Inspection by Date Final Inspection by Dater Additional Comments: ❑ Stk 466-6781 'i I❑ Lodi 369-3621 `-” ❑aManteca `823-7t04�, ❑ 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 CASH RECEIVED BY GATE PERMIT'NO. 60 +.EH1324 tREV.1",5) 03� -D-i EH 14-28 / p(-} w E