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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _ PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) ,0^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 I 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 Diistfrict. Job Address, . �F - City i �' Lot Size PM LU. Q 15173 gs2�7 _Owners.Name_ L&'vLkn^#^�' �' •Address- �u�• ---Phone. Contract au `�'C ` `1^ Address `a � License No. � Z z Phone �"�p' /0 _ r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ a DESTRUCTION ❑ PUMP INSTALLATION_ ❑ -- �' -' ' SYSTEM REPAIR ❑ OTHER ❑ 77 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �-- ---^� FOUNDATION AGRICULTURE WELL -'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom EI-Manteca Dia'of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy u. Type of Casing Specifications ❑ Public ❑ Other ❑ Delta./"- Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth IO Eastern Surface Seal Installed by Repair Work Done ❑ Type,of Pump H.P. State Work Done J Well Destruction ❑ Well Diameters Sealing Material (top 501 Depth Filler Material (Below 501 1; + TYPE OF SEPTIC WORK:' NEW INSTALLATION e REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system permitted if public sewer is �p�,: available within 200 feet.) 1). Installation,will serve: Residence_ Commercial_ Other h Number of-living-units.: Number-o b drooms ® I Character of soil to a depth of 3 feet: '� ' - Water'table depth SEPTIC TANK W-Type/Mfg C Cafiacitylkl Compartments. l PKG. TREATMENT PLT. ❑ r i•' Method of Disposal f. Distance to nearest: Well 00 .t Foundation _/00 Property -LEACHING LINE R!'-No. & Length of lines - - " Total length/size FILTER BED El Distance to nearest: Well ld d)0 Foundation /�Q— Property Line 20 r SEEPAGE PITS I?' Depth Size j q? - Number -�] � ------r_r �(} SUMPS ❑ Distance to nearest: Well-/.-�� Foundation" %a4 11"'4 Property Line�c�^'_— - {{77"►► 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 District. 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,1 shall employ persons subject to workman's compensa- tion laws of California." The app77!F7 ' ' spections. Complete drawing on reverse side. 01 Signed Title: '�' Date: FOR DEPARTMENT USE ONLY -Application Accepted by Date Area W �?ate Pit or Grout Inspection by Date to Final Inspection by Additional Comments: �` t D Stk 466-6781 Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy 6365 Applicant - Return all copie • Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +EH 13.24iREV.�ie51 +. Jar 13A ? EH 14-26 I