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`/f1( APPLICATION FOR PERMIT IQ SAN JOAQUIN LOCAL HEALTH DISTRICT 3,44� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 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 L�1L l�/" AC� City � — Lot Size PM Owner's Name �/`Y�� v!'/"-��_ S Address Phone + � ContractorAM" Address p f��f��t— �'License No. Phone TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ -'PUMP INSTALLATION K 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 El Open Bottom El Manteca Dia. of Well Excavation Z 4ia. of Well Casing Domestic/Private ,Gravel Pack ❑ Tracy Type of Casing__ / Specifications Public Q OOjther [-IDeltaDepth of Grout Seal / Type of Grout I I Irrigation t�iil4pprox. Depth I I Eastern Surface Seal Installed by/W95,U A Repair Work Done` ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth r= _-.Filler-MaterW (Below 50'1 -- TYPE OF SEPTIC 4/ORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic syste permitted if public sewer is available within 2PO feet.) Installation will s rve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil ko a depth of 3 feet: Water table)depth SEPTIC TANK I E3 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of isposal Distance to nearest: Well Foundation Property Line_ " I. LEACHING LINE ❑ No. & Length of lines Total length/size c� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size M_ 1Niurnber SUMPS ❑ 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 rules and regulations of the San Joaquin Local Health Diltrict. ((( 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 s . rr quir % ns. Complete drawing on reverse side. Signed X �� // ` Title: 14v,,4 Date: " FOR DEPARTMENT USE ONLY — Application Accepted by ca L 7 Area Pit orProug Inspection by Date G Final Inspection by s:,_ Date1_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 A OUNT DUE AMOUNT REMITTED CK RECEIVEDBY DATE PERMIT NO. INFO CASH r.EH 13-24(REV.t/H 5) �1 ( O '� &kA EH 14-26 V