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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT h 1601 E. HAZELTON AVE., STOCKTON, CAS �A Telephone (209) 466-6781 �"� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Aistrict for a permit to construct and/of 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. LAACity L.AA Lot Size PM Job Address r 1 I-U S rL .�`� �7 d Q yw+ ,l _ Phone S T A47D Owner's Name W^!0'tLA Address Contractor J � Address �. License No. Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca ation Dia. of Well Casing Dia. of Well Excav Type of CasingSpecifications ' ❑ Domestic/Private ❑ Gravel Pack [� Tracy r'1 Public ❑ Other L1 Delta Depth of Grout Seal Type of Grout--- 1 rout —1 1 Irrigation —:,--_Approx.;Depth,,,,•1,1,Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ 1 Well Destruction ❑ Well Diameter € Sealing Matenak (f60'50'I a Depth i •.Filler_Material (Below 501'°" TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION [N I DESTRUCTkO (No septic system permitted if public sewer is (, vailable within 200 feet.) Installation will serve: Residence— Commerciai— Other Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ , IMethod o1"Disposal Distance to nearest: Well Foundation ,Property Line ' LEACHING LINE ElTotal length No. & Length of lines +h/size 4- FILTER BED ❑ Distance to nearest: Well Foundation Property Line i .. .,_ . .,.�....._..,� SEEPAGE PITS 11 YDeptFi Size — Number SUMPS Ll 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 San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature certifies the following:'"'(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 certifiesthe folio -ng: "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 Ca' ia." `" The applicant call for all re it inspect ns. Co plate drawing o rse side.[( Title: Date: Signed �. R DEPARTMENT ONLY Application Accepted by Date ^reg Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ffManteca 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 i FEE AMOUNT DUES tAMOUNT;MITTED CA5H RECEIVED BY PATE PERMIT No. I INFO )� /� ��fJ F +.EH 1324 tREV.1/x 51r 66 . t1 IV � � �� V EH 14-2e_