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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2099) 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 k 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. (�� ' 4 PM Job Address 130 (-L City Lot Size qqo Owner's Name Address Phone l0 i Contractor's Name Lia—r—" 141 License No. 3< Phone [ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w 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 ,i Dia.-of Well Excavation Dia. of Well Casing = "='❑_Domestic7P"nvatd "❑'Gravel Pack— C7-Tracy�Tg.Wof-Casing - """ -'Specifications—'-- _4�I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout W ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by C 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 1 TYPE OF. SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' r available within 200 feet.) c Installation will serve: R 'dance 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 apacity lQf6 D No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal ' ' Distance toynearest: Well] [Q0 Foundation v16r Property Line LEACHING LINE ❑ No. & Length of lines Q1 �._ ToTal length/size FILTER BED ❑ Distance to nearest: Well 0!�' YF 'Foundation 40 Property Line 7 130 r SEEPAGE PITS ❑ Depth Size 3 Number SUMPS ❑ Distance to nearest: WellO— Foundation IA!__ Property Line DISPOSAL PONDS ❑ - .- -1 . 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. :'Y Home owner or licensed agent's signature cert�es the following: "I certify that inFthe performance of the work far 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.-Contractors hiring or sub-contracting signature certifies the following:"I certify that in t a performance of"the work for which this permit-is issued,1 shall employ.persons subject to workman's compensa- ti f California." The applican I ior II uired specti m late drawing on verse side. Q' ;, Signed T'rtle: Date. FOR DEPARTMENT USE ONLY . Application Accepted by 1 Date Area iJ Date c.J� ('0 Final Inspection by Date Pit or Grout Inspection by Gam Additional Comments:. ❑ Stk 466 781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 T - ----Applicant- Return all copies to:-Environmental Health Permit/Services 1601 E. Hazelton Ave;, P.O:-Box-2009; Stk.., CA 95201.•- AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PEfiMIT-NO. FEE CASH INFO EH 13-24(REV.10183) 45,°° 4-M a �` 3ed-56b EH 114.213