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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZE T ON 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. ti" Job Addressat1 7 City ' `Lot Size ��n r PM Owner's Name re t LLZ LN —r Address `f Phone Contractor 66tk-��% ,Address 7 �c License Flo.t"1a 1" Phone ' P TYPE'OF WELL/ MP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FLD. PROP. LINE ;l€ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _$ k 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 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout CID Sur ace Seal Installed by 1 ❑ Irrigation ---Approx. Depth EI Eastern �,�., ) , Repair Work Done. ❑ Type of Pump H.P. ' I State Work Done Well Destruction ❑ Well Diameter Sealin§-Material {top 501 I ' t ,Depth """"" Filler Matefial fBel0w-50')—1,--•, ' l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION iNo septic system permitted if public'sewer is available within 200 feet.) , Installation will serve: Residence Commercial— Other N, . Number of living units: j Number of bedrooms Character of soil to a depth of 3 feet: >I Water table depth l 3 • SEPTIC TANK Type/Mfg Capacity No. Compartments _ PK G. TREATMENT PLT. LJMethod of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE O No. r;, Length of lines ` tri Total length/size FILTER BED L� Distance to nearest: Well Foundation s Property Line SEEPAGE PITS O Depth i Size Number = s SUMPS O Distance to nearest: Well Foundation Property Line ? DISPOSAL PONDS ❑. t 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: "1,certify that in the performance of the work for which this pefmit is issued, I shall not t' 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: '9 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." t i The applicant call for all required inspections. Complete drawing on reverse side. Signed Title: Date: (rte �� j FOR DEPARTMENT USE ONLY Za-_Application Accepted by Date Area Pit or Grout Inspection Date Final Inspection b Date Additional Comments: V" ❑ Stk 466-6781 '" ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O:'Box 206WStk7CA FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'N0. INFO f+ EH 1324{REV. /45) 3 S 123 ' � + � 178� Z3at f EH W26