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I+ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,I ON AVE., STOCKTON, CA 1° Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : . (Complete in Triplicate) ' Applications 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 F Local Health District. J. t i. �. }• Job Address / l&9", �+� ` r = City&t�� Lot Size PM s+ Owner's Name VUfta�� Address Phone r Contractor's Name LErN L%—License No. TYPE OF WELL/PUMP:- `�` .k ' NEW WELL ❑ --WELL.fiEPLACEMENT`❑ _DESTRUCTION 0� MP--INSTALLATION ❑ SYSTEM,REPAIR'© OTHER EI DISTANCE TO NEAREST: SEPTIC TANK — _ _ SEWER-LIN-ES 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 Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L5 i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ! ❑ Irrigation ---LApprox. Depth ❑ Eastern -. Surface-Seal..Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ' i j a w M Depth Filler Material [Below 50') ----- S TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_Commercial_ her Number of living units: -'— Number of bedrooms Character of soil to a depth of 34eet: r = c Water table depth I SEPTIC TANK �❑ Type/Mfg - .Capacity — No. Compartments P-KG.TREATMENT PLT�❑j` ' 'Wpr�E�� '�" 1 Method of Disposal' v Distance to nearest: Well Foundation Property Line LEACHING LINE ElNo.Y$I Length of Iines�T i —' Total length/size j r A ' i ` r—j FILTER BED ❑ 3Distance to nearest: Well t ,'Foundation[ Property Line 211 SEEPAGE•PITS N ❑-,Daptla {"'"'^"""Size � � � Number f . SUMPS distance to nearest:,.4 Well Foundation'--Zb� Proparty Line DISPOSAL PONDS , ❑ i` l hereby certify that I have.prepared this,applicatio""-n-70fid that the work will be done in accordance with San Joaquin county ordinances, state laws, and �u1es'and regulations of the Sari Joaquin Local Health District. t-1; -�- I Home owner of licensed agents signature certifies the foliowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not i employany-person-in°such.manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature l �,,rtffies the following:"I certify that in the performance ofthe work for which this permit is issued, i shall employ persons subject to workman's compensa- California ,-="- --�m �.- .-�-n.�applica ust call fo all r quire i specti ns. Co to drawing- reverse side. �, , Signed itle. Date: FO DEPARTMENT USE ONLY _ Application Accepted by Date -_7 _ � � Pit or Grout Inspection by I, Date f Final Inspection by . pate Add}'ion Comments: I° !j�tk_486 6781 ❑ Lodi 369 3621 ❑'Manteca 823-7104 ❑ Tracy ..;3r 6385 /Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNF REMITTED "JP RECEIVED BY DATE PERMIT"NO. INFO CASH �{ 7-71f + EH 13-24(REV.10183) � � ��D EH 14.26 _. II