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d APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. / Job Address a LA 62 S9 N "IAX 11-_w7 n City Lot Size 4_r1 C leG,SL_ PM Owner's Name Address (F-Le P-i) ke t± FIX41 _ Phon Contractor * ' Address 6L y �TLicense No.eaL(W a R3 Phone 4' yr 2 7 TYPE OF WELL/PUMP: W WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ "PUMI•iNSTALLATION -SYSTEM REPAIR ❑- OTHER LI_ DISTANCE TO NEAREST: SEPTIC TANK -_/Qpt SEWER LINES DISPOSAL FLD.14_0 PROP. LINE1_3=::�_ FOUNDATION h�_.D AGRICULTURE WELL-Ay-A4,- OTHER WELL9LV,&e PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r t t ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C�l(pomestic/Private ID Pack Q'Tracy ' Type of Casing- Specifications r�� FI Public FI Other ,❑ Delta ,Depth of Grout Seal / Type Groutce,5 Gct�1 I I Irrigation —.Approx.. Depth Repair Work Done ❑ Type of Pump � H P. _3 _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 4 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 {No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 6 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments CD PKG, TREATMENT PLT, ❑ 41 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 SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line r' DISPOSAL PONDS ❑ 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, ander rules and regulations of the San Joaquin 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 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 work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections-Complete drawing on reverse side. Signed X Title: dr% Data: 1 FOR DEPARTMENT USE ONLY } Application Accepted by (/J Date Area Pit or Grout Inspection by Date ZZ Od Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 " Applicant - Return all copies fo: Environmental Health Permit/Services 1601 l=. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE • INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. a.EH13-241REV.r/M51 EH t4-2e r