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APPLICATION FOR PERMIT ff� SAN JOAQUIN LOCAL HEALTH DISTRICT d. LP 1601 E. HAZELTON 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. e Job Address � JJ X50 � �r� City Lot Size PM -... 1 � o Owner's Name Q� Address 73 �i�rrQ �r1P Contractor_ V��?ncnc �0� Address Gt�tGcense No. 2 f1 YO Phone TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Cw PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO._/1171 ' PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing KI Domestic/Private i'r Gravel Pack-•- [X Tracy Type of Casing Specifications F] Public Cl Other F1 Delta Depth of Grout Seal T pe of Grou I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by- Repair - Repair Work'Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth T Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION 11-(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" Capaclty ' `No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ i _ 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 I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line a DISPOSAL PONDS« ❑ - -- f 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: "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 Ca.fornia." The appli t ust call for requi inspections. C mplete drawing on evers side. Signed X Title: L&J Date: �- a _ '. FOR DEP�RTMENT USE ONLY Application Accepted by Date `( � Area Pit o G t Inspection by / Date✓ ,:!�?� Final Inspection by tura Date Additional Comments: lr s �QUt 0 PAYMENT ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca U3-'A04 ❑ Tracy 835-6385 RECEIVED Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Silk., CA 95201 F CCB 22 198E FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. CK 11 INFO CASH �r� �Q r� � E STH i. + EH13-21(REV.r/H5) S EH 14-2a