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APPLICATION FOR PERMIT ; SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /? ,333 CCo"4z- (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ASL' (SEL Cal-M5 Job Address _Ir t _ _T f[F�II" .�� t`D�`ty/9�/((�Lr' City I of Size- 'X . PM Owner's Name Lcutt� f Address t�e7_ �. [(JItLLeX . Kr'([LC� Phone 7_07-7V —k-11W F p / t� Contractor Address 1Q CM2 License No. q!� ,/3 Phone ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK _-f 0he SEWER LINES DISPOSAL FLD. PROP. LINE 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USS-_ -TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS � El Industrial 11 Open Bottom f El Manteca Dia. of Well Excavation Dia. of Well Casing 1A Domestic/Private k Gravel Pack t Tracy Type of Casing Specifications l Public n Other Cl Delta Depth of Grout Seal fns Type of Grout & C I I Irrigation r Approx. Depth [ I Eastern Surface Seal Installed by dlazm )2 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 INSTALLATION I:I REPAIR/ADDITION i I DESTRUCTION ( I (Na septic system permitted if publicsewer is f 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 F PKG. TREATMENT PLT:❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS € I Depth Size Number ' SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di?;trict. Home owner or licensed agent's signature certifies the following: "I 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." f The applicant ust call for all re ired inspections. Complete drawing on ersee side. Signed X Title: C " Date: " `7/� DEP R ENT USE ONLY Application Accepted by '?Date 1/ 7 Area Q Pit or Grout Inspection by Date �t Final Inspection by Date ' Additional Comments: 1f �9- C1 Stk 466-6781 ❑ Lodi 369-5621 ❑ 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 t INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. +.EH1 -241HEV.t/rill EH 144-26 /