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APPLICATION FOR PERMIT rt SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address / y' js/ �� sat City Lot Size X f`3� PM X Owner's Name �tr I E L Address *7'• Lr! LGA/" ?(Owner's \ C � _ Phonl' e � O%i` / Contractor _- Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNQATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS _ 3 + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom'"s ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r� ❑ Domestic/Private ❑ Gravel,' I Tracy Type of Casing Specifications ❑ Public 1-1 Other �1 '` f 1 Delta Depth of Grout Seal Type of Grout-.--. `t 1 I I Irrigation 4-Approx. Depth I ) Eastern Surface Sealinstalledby VVV Repair Work Done El Type of Pump H.P. State Work Done Well Destruction ❑ WeII,Diameter Seating Material (top 501 Depth } Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION i 1 DESTRUCTIO (No septic system permitted if public sewer is f •r r(ob)e within 200 feet.] Installation will serye: Residence_( Commercial_ Other Number of living units: Number of bedrooms. Character of soil to a depth of 3 feet. Water table depth ,SEPTIC TANK. ❑'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance,to nearest: Well —p._ Foundation Property Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance}to nearest: Well Foundation Property Line- - --"' SEEPAGE PITS i I Depth Size Number 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 SSn Joaquin county ordinances, state laws, and rules and regulations of the San Joaqu#n 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 shati 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,-I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust Call for all required inspections. Complete drawing on reverse side. Signed X Title: O"e Date: 4!� FOR DEPARTMENT USE ONLY 1 Application Accepted by _ Date TiZKArea Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: -7/s,7 74 �9 .2 3� ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 f FEE INFO AMOUNT DUEJ AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT'NO. r.EH13-24 1REV.1/H 5Y tn 5:i-% EH 14-28