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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 2� 1601 E. HAZEL 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. C / Job Address A,4 f' Cityt-� cpl.ot Size—,C PM Owner's Name Address LA S 24 AJ R/ Phone Contractor � ,/ A4Bess 0 S License No.1J 6 0 92Phon 3 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 FI Public n Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I I (No septic system permitted if 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ,�/�+ PKG. TREATMENT PLT. El Method of Disposal w 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 ( I Depth Q Size .2_ ! Number SUMPS ;K Distance to nearest: Well Foundation Property Line 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, and 4 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: Date: J ^FOR DEPARTMENT USE ONLY Q Application Accepted by �� ,.c lam` Date SLI Area Pit or Grout Inspection by Date Final Inspection by i 4 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 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY GATE �p �(P/ERMIT NO. + EH 13'24 EH 14-26 (REV.tills) t� 7 6 &0 C�— � Y / i!/`y�