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APPLICATION FOR PERMIT �, . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE., STOCKTON, CA ! Telephone(2091"466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED t (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.544 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address W1 wR City&6Size PM Owner' Name LSAcldress t Phone y s Contract Address_ © P,D k [ License No. Z3 7 Phone ;yam\ TYPE OF WELL/PUMP:- NEW WELL _+WELL REPLACEMENT ❑ �DESTRUCTION ❑ - 4PUMP INSTALLATION ❑ ~SYSTEM REPAIR Ll {` �"" OTHER—E) DISTANCE TO NEAREST: SEPTIC TANK'_ SEWER LINES DISPOSAL FLD. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑ I dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Coomestic/Private Gravel Pack`` ❑ Tracy Type of Casing Specifications E'1 Public ❑ Other 1 �elta Depth of Grout S Type of Grout _ I I Irrigation --Approx. Depth { I Eastern Surface Seal Install- I'I Repair Work Done ❑ Type of Pump H.P. State Work Done_ ti Well Destruction ❑ Well Diameter Sealing Material {top 50'1 4. Depth I Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 17 1No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence 'I Commercial_ Other Number of living units: Number of bedrooms ? Character of soil to a depth of 3 feet: —�-- -- —^—Watertable depth t SEPTIC TANK ❑ Type/Mfg Capacity l No. Co partments PKG. TREATMENT PLT. ❑ osal{ Method of Disposal f � p Distance to nearest: Well FoundationPr perty Line LEACHING LINE ❑ No. & Length of lines: Total length/size FILTER BED ❑ Distance to nearest: Well i Foundation I I Property Line t SEEPAGE PITS l I Depth Size_ Number SUMPS ❑ Distance to nearest: Well Foundation :.----�- �^-Property-L-ine• DISPOSAL PONDS ❑ I " 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 an Joaquin-Local Health District. , Home awner or Ii ed agen signature certifies the following: "I certify that in"the performance of the work for which this permit is issued, I shall not employ any per n in such ma era to come su to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the lowing: "I ce ' that i nc ft ich this permit is issued, I shall employ persons subject to workrnan's compensa- tion laws California." The appl- an cal r all r �r Com ete drawing o r se sid Signed Title: FO EP T.USE ONLY.-- •Y "�T O Application Accepted by Date Area e Pit or Grout Inspection Date --��—""'Final Inspection by Date 6'-'z �O f-pec Additlonal'Comments: _El Stk 466-6781 ❑ Lodi—369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant; Return ail-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE i AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT"NO. j k 1 ♦.EH1 '241REV,tiK51 , [�0 C ' EH t44-28 lO VV Lei