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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH. DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone.(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a =� {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:t. .::�,� Job Address Ne-.P- d1 Lem r WtE.[/ City L r,A I Lot Size PM f. Owner's Name E Address Ng_ LTJ i h e-10ta..s` W_f S , Wa om Phone Contractors - -��-�h bit �S6 Address 9ai'1 s—13USJUes5 RADI License No, Phone TYPE OF WELL/PUMP: Mfn, r—N WELI_)MvWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 "f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation < Dia. of Well Casing Domestic/Private �❑ Gravel Pack 11 Tracy Type of Casing �V� -Specifications ❑ Public f Other ❑ Delta Depth of Grout Seal Svr. Type of Grout fack Rel � 171Irrigation w _--Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth IFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: 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 ~ J PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Q No. & Length of linesTotal length/size FILTER BED ❑ Distancetonearest: Well Foundation Property Line SEEPAGE PITS 1 ❑;.. Depth Size Number I SUMPSL, ❑ 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 accbMance 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,I shall employ persons subject to workman's compensa- tion laws of California.". The appiican must call f r all r uir spections. Complete drawing_on reverse ide. G y Signed Title: Date: O~ L FOR DEPARTMENT USE ONLY _ ' ,[io,�• �� Application Accepted by Date Area t Z 7 Pit or Grout Inspection by Data L7 � Fina! Inspection by LiY�.t.Q.w.r�__— Date P6 lr Additional Comments: f ❑ 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, Stk., CA 95201 s" r FEE AMOUNT DUE' AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO CASH EH 1324(REV. /e5l 3s°g I I. EH 1428