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APPLICATION.FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1 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 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 Local Health District.:_ "° I Job Address City C 1 Lot Size PM Owner's Name T15 1 �2o-1u�ll Address Phone Contractor - 41LC 1 Address Y.Ua � 9 /� ��+ License No.a�s� Phoneme Ya�ll 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 I w FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , I ❑ Industrial ❑ Open Bott ❑ Manteca Dia. of Well Excavation `' Dia. of Well Casing i ❑ Domestic/Private L1 Gravel Pack ❑ r Type of Casing Specifications ❑ Public ❑ Other ©Delta��, �{ a th of Grout Seal Type of Grout I ❑ Irrigation �Approx.`pepth''„i] Ea Surface Installed by a ' Repair Work Done ❑ Type of Pump `�H.P. 1.,�. Work Done''”" i Well Destruction ❑ Well DiameterSealing Materjal {top 50'I I 1 Depth Filler Material (Below50'1. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION'❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer iso e available within 20.0 feet.) Installation will serve: Residence Z6ommercial_ Other 41 Number of living`uriim Number`of-bedrooms Character of soil to a depth of 3 feet: c k&A A4 Water tattle depth SEPTIC TANK ❑ Type/Mfg t Capacity 40 No. Compartments # �. PKG. TREATMENT PLT. ❑ F`gJ: Method of Disposal a Distance to nearest: Well 0 FouPdation � Property_Liie LEACHING LINE ❑ No. & Length of lines -Total lengthlsize FILTER BED ❑ Distance to'nearest: Well'.:!/92 . Fou'ndation 'A3+ Property Line SEEPAGE PITS L: Depth _/� Sizel .` / �� Number SUMPS ❑ Distance to nearest: Well ( Foundation t.4T, U ' Property Line DISPOSAL PONDS ❑ j l hereby certify that I have prepared this•application.and that the work will tie done in accordance with San Joaquin-county ordinances,state laws, and rules and regulations of the San.Joaquin Local Health District. ) ;x ► I Home owner or licensed agent's signature certifies the following:."l certify,that in the performance of the work for which this permit is issued,'I shaWriot 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 n.ork for which this.permit is issued,_l shall employ persons subject to workman's compensa- tion laws of-Cillifomia-' ---+--e l ' The applicant must call r all uired inspections. Complete drawing on reverse side. Signed Title: -L'-- Date: Da Cp ! I t = �.� D" i ` FOR DEPARTMENT USE ONLY Application Accepted by Date '� b�W- Area t _ t j Pit or Grout Inspection by Oate Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% � I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'1V0._� t. j� all ...a.-4-EHA3-24-(REV.1./.86) EH 14-28 (/ - - �• ' i