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Y � k ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. y�p Job Address 1 � �-�� City Lot Size PM Owner's Name L 1 Gx'cT L p Address Phone Contractor Address v License No.12 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP`INSTALLATION-0 --- 'SYSTEM REPAIR-0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER I_INE5 DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -. PITS/SUMPS INTENDED"USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial- , -,r• ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing ❑ Domestic/Private �❑ Gravel Pack ❑ TracyType-of Casing` Specifications f'l Public IN Other M Delta Depth of Grout Seal Type of Grout - i I Irrigation "L-Approx. Depth I Eastern Surface Seal Installed by ° € Repair Work Done ,0 Type of Pump H,P. State Work Done_ Well Destruction p Well biameter Sealing Material )top 50') Depth -. - . Filler..Material (Below 501 TYPE OF SEPTIC'WORK: NEW INSTALLATION} REPAIR/ADDITION I 1 DESTRUCTION l I (No,septic system permitted if public sewer is f available within 200 feet.) Installation will serve:, Residence Commercial_ Other [ -- I- .. Numbe of living units: �� Number of bedrooms 3 ! Character of soil to a depth of 3 feet: Water table depth I( SEPTIC TANK ❑ Type/Mfg f Capacity p No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well "� FoundationProperty erty Line �?Wr LEACHING LINE IYL No. & Length of lines - Total length/size FILTER'BED :MET--D'i'stance to;nearest: Well �a Foundation Property Line SEEPAGE PITS "^I 1 Depth F7 Size y '" Number e� ._ s SUMPS �' - 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 r rules and regblaiions of the San Joaquin Local Health District. r 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 signaluYe r 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 CAliforaia." ' e The applicant must calf f all req 'red inspections. Complete drawing on reverse side. z Signed X Title: .. Date: OR ARrMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by� �" I Date Fina$.lnspection by Date i� Additional Comments: ❑ Stk 1466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.'O, Box 2009, Silk., CA 95201 FEE INFO "4AAOfli+1T pUE `"AMOUNT CK. CAS+1 'RECEIVED BY DATE �f'ERM17 N�,.4 r. rEH 13-24 tREV.-,]%n-51 _ T c EH 11-28 w e;