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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT III 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. Q!I/� Job Address05-1-f 7 /w/.• l t /L-91 City Lot Size 94:L4� PM Owner's Name 1AA-2 Address 7 ` � Ph., P?1 �/ s /4O/q _ Contract r' Address i�0 70 Cj2E License No32Y2A- Phone faf 10 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. ❑ Domestic/Private ❑ Gravel Pack a Tracy Type of Casing Specifications 11 Public ❑ Other 17 Delta Depth of Grout Seal Type of Grout . I I Irfigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ DDITION DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Re idence_ Commercial Other Number of living units: / Number of bidrooms� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg J Capacity ,11� No. Compartments PKG, TREATMENT PLT. ❑ f ( Method of Disp?sat Distance to nearest: Well Foundation Property Line LEACHING LINE, No. & Length of lines T9tal length/size �-� FILTER BED ❑ Distance to nearest: Well L� Foundation f Property Line (577 SEEPAGE PITS' ?4 4r1 Depth Size 4199Number �. SUMPS d LlDistance to nearest: well 100- ..__ Foundation �� Property Line L:!;— 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 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 applicant t call for all qui din coons. Complete drawing on reverse s�id Vol Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepte by Date �y Area 6Vit r Grout Inspection by Date Final Inspection by Date r Grout Inspection by I- i Additional Comments: ❑ 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 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE I PERMIT'N0. +.EH 14-24IREV.tik51 /t .7 —O `� EH -26 LIZ I