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APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED ` y . F (Complete in Triplicate) '. ....�... � ,. r,..l . 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 Ryles and Regulations of the San Joaquin Local Health District. c` gq�To,S k .�k Q��d Wig" L p7 S Job Address j� " f City 714 A L;t Size—//�" � j �PM Owner's Name - Address -Phone ContractorLiGLE/'� Address C License No. '�?�� Phone TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ff OTHER ❑ DISTANCE TO NEA4ST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ❑ Industrial '� ❑ Open Bottom ❑ Manteca Dia. of Well-&cavation Dia. of Well Casing ❑ Domestic/Private C] Gravel Pack ❑ Tracy Type^of C sing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation /i --Approx. Depth ❑ Eastern Surface Seal Installed by ( 9 S Repair Work Done ❑ Type of Pump H:P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') i LA Depth ,rr Filler Material (Below 50') l � TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available withir1,200 feet.) '. Installation will serve: Residence��/ Commercial_ Other i=ce _ — _— . .t . NumberNumberof living nits: = Number of'beclrooms i Character of soil to a depth of 3 feet: ' Water table depth I SEPTIC TANK tI Type/Mfg Capaclty,� )No. Compartments } .s PKG. TREATMENT PLT. Elj Method of Disposal } Distance to nearest: Well Foundation 4' F r Property Line__'SO �T� j I.,;t 41 f ,LEACHING LINE No. & Length of lines ' L Total length/sizeD FILTER BED ❑ Distance to nearest: Well Foundation ee!�2 Property Line_JZ SEEPAGE PITS 11u?n Depth "Size Nber SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinancesI-state laws, and rules and regulations of the San Joaquin Local Health District. r - •- s Home owner or licensed agent's signature certifies the following: "I certify that in the performan a 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-cis issu&d,Iisihall not r° certifies the following:"I certify that in the performance of tFie-iv6rk-forwhich this perrllit4s issued, I shall employ persons subject to workman's c8mpensa- I tion laws of California." ! The applicant•must call for lire red inspections. Compete drawing on reverse side-4 E :-Signed Title: _ Date: r- — _--FOR DEPART�r:NT USE ONLY Application Accepted byDate z'i� 3 Area 4)✓ Pit or Grout inspection by. Dated �� Final Inspection by Da,e, Additional Comments: �F ❑ Stk 466=6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83Er6385 ' Applicant- Retufn'all'copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I 6 i 1 FEE AMOUNT DUE AMOUNT REMITTEDCK __INFO _ ,CASH.. RECEIVED BY DATE PE]RMOT" ':+•EH 13-241REV,-i/a 5Y EH 14-26 -� �^......— --....