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APPLICATION FOR PERMIT S'N JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. HAZE T ON AVE., STOCKTON, CA ^'' ;I Telephoie 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED af' i (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. :I�1 Job Address /�L� �', Cit Lot Size PM Owner's Name ,L1L1a(,_,C, JAddress Phone �t .,1.�l, w " Contractor �A l L-T r1'kL L �QIL�S ddress ��i� 1�License No +� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'i DISTANCE TO NEAREST: SEPTIC TANK. _ SEWER LINES DISPOSAL FLD. PROP. LINE I F FOUNDATION �,AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial " - ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LJ Gravel Pack ❑ TracyType of Casing Specifications L M Public ( 1 `Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation -Approx. Depth [ I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Dane_ Weil Destruction ❑ Weil Diameter Sealing Material {top 501 -Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION o septic system permitted if public sewer is 41 - available within 200 feet.) Installation will serve: Residence_ Commercial 4-tether - l Number of living units: ? Number of bedrooms Character of soil to a depthliof 3 fedi Water table depth SEPTIC TANK ❑ "Type/Mfg Capacity—I- No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal 'Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines" Total length/size FILTER BED ❑ "Distance to nearest: Well Foundation Property Line L6 ! i SEEPAGE PITS ( I ""!Depth j Size h Number SUMPS y El-'Distance to nearest:" Wel! Foundation._-�_ Property Line DISPOSAL PONDS �' ❑ I hereby certify,Ithat I-haye prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regr5laii6ris of the Ser+boaquin 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 pl e oy any person in such manner asfto become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ce s the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion la f California." .• -..�- . ,�-.— _-._ _�..e, ,___, The applican st all for all�r quired -Hsps ti rm rete awing on r arse std j '! Title: _ Date: II FOR DEPARTMENT USE ONLY Application Accepted by Date ' F =rea �� r Pit or Grout Inspection by IPf Date Final Inspection by Date 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 FEECK INFO AMOUNT DUE F AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.I/H 5) + �x�x/ EH 14-26 - I�� 7� '�DO "A07 IL I