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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' {Complete in Triplicate) `' 3k �� a�f� 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. 3� Job Address �• } z City Lkm& P Lot Size PM Owner's Name �; �R L1AlIV D Address Phone 1� 1l Contractor's Name ` License No. D Phone _ G 74 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK a / SEWER LINES DISPOSAL FLD.` PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation_ ' Dia. of Well Casing{ Domestic/Perivate ❑ Gravel Pack ❑ Tracy Type of Casing �L Specifications ❑ Public V Other j ❑ Delta Depth of Grout Seal { Type of Grouts El Irrigation �_�pprox, Dept Eastern Surface Seal Installed byl' �-� Repair Work Dot ne, © Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i V Depth iI Filler Material (Below 501 i 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I" available within 200 feet.) �` r 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 I PKG. TREATMENT PLT. ❑ Method of Disposal (^� Distance'to clearest: Well ' .Foundation Property Line -� :I % 1 LEACHING LINE ❑ No. & Length of lines f ' Total length/size FILTER BED ❑ distance to nearest: Well Foundation Property Line SEEPAGE.PITS f ❑,.,Depth Size Number SUMPS{ ❑ Distands'to nearest: -Well-__.. _.�-.—�--foundation Property Line 1 DISPOSAL PONDS lfT ❑ = ; !Ehereby certify that,l-have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;state laws, and rules'and regulatioKis of the San Joaquin Local Health District. r— -• .,�4 F'`" Home owner orrlicensed agent's'signature certifias'tFi�foEliiwmg: "I certify that in the performance of the work for which this permit is issu6d, I shall not 0 employ any person in such manner as to bedome subject to workman'soompensation laws of California." Contractors hiring or sub-contracting signature certifies the f lowing:"I certify,that,in the performance of.the work for¢which this permit is issued, I shad employ persons subject to workman i compensa tion laws of Iifomia." The applican ust call f Ir al equ i spectio' Complete drawingion reverse side. ✓j; r Signed - �-- Title: Date: eT_ FOR IDEP#T NT USE ONLY f3 Application Accepted by � Date Area � r Pit or Grout Inspection by � � Date � Final Inspection by � �" Date 2z - � ,_,_,_.�_.v.... *-•--.;-.»sem--.,—w,,.;._�_ " . . -«-w.-� Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3521 Manteca..k&7104-'`^a``El-Tracy 8354385 Applicant- Return all copies to: Environmenta 'He' th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 FEE AMOUNT DUE AMOUNT REMITTED 'CASH RECEIVED BY DATE PERMITNO INFO Q'QD + EH 13-241RE'V.10/631 L) EH 1428 bS C] f/ - •V �� a1-743.