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APPLICATION FOR PERMIT LOUSAN JOAQUIN LOCAL HEALTH DISTRICT f 3 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES i 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 [ 7 � /C!_ � ! {f,,�j ` City Lot Size PM Owner's Name T .s��C,� ��N !l4 P-1 A J / /MAO Tls'T2 G Address Phone � . 01 Contractor "� Address -2 1,2m& 1"kC6) License No. Or6 Phone i TYPE OF WELL/PUMP: NLeW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �4- SYSTEM REPAIR ❑ OTHER ❑ 1 f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD.r PROP. LINEt f I FOUNDATION fi AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Well Casing 3YDomestic/Private 'Gravel Pack ❑ Tracy Type of Casing �✓'L 0,Specifications` J l7 'Public Cl Other ❑ Delta Depth of Grout Seat C) Type ofGrout—&;CAM/V I I Irrigation 30OApprox. Depth I I Eastern Surface Seal Installed by 5 Repair Work Done ❑ Type of Pump - H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') _ FF TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION 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 rri f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i I PKG. TREATMENT PLT. ❑ i 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 > 1 7 ! SEEPAGE PITS i I Depth Size Number SUMPS 0 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 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 pi employ any person in such manner as to become subject to workman's compensation laws of California." Contr`ctor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ arsons subject to workman's compensa- tion laws of California." The applicant INI req m Complete drawing on re rse side. Signed X itle: Dater FOR DEPARTMENT USE LY /d--9 �2- Application Accepted by Date � Area ` Pit or rou Inspection by �` Data Final inspection by -�iJ'.1l/ rte Date Additional Comments: ❑ Silk 466-6781 LJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 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 CASH RECEIVED BY DATE p PERMIT'NO, +.EH 13-241REV.1"51 r�x,675 S `I+r f�t 1� ,(� /o- sT'l EH 114.28 - _