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APPLICATION FOR PERMIT t 7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR 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 / Y B �&/'7t—/ lt-'�yty �t� aot Size PM `\ Owner's Name 4 m {'7 Letya— Address a�`�' Phone �a , Contractor dress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E 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 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications I`l Public ❑ Other ❑ Delta Depth of Grout Seal. Type of Grout — I I Irrigation Approx. Depth , l I Eastern Surface Seal I stalled by Repair Work 'Done ❑ Type of Pump H.P. -State Work Done_ Well Destruction ❑ Well Diameter f Sealing Material (top 501 '- Depth Filler Material 1Below 50') ' TYPE OFFS PTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence=. Commercial f_ Other Number of living units: Number of bedrooms IFCharacter of soil to a depsh'of 3 feet: Water table depth t SEPTIC TANK ❑ _Type/Mfg Capacity Nd'Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property-Line LEACHING LINE ❑ No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well ._Foundation Property Line SEEPAGE PITS ['I• Depth Size __ Number I SUMPS t ❑ Distance to nearest: Well Foundation Property Line ; DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 inspection Complete drawing on reverse side. o ` Signed X Date: 'fir (0_4 C` JFOR DEPARTMENT USE ONLYU-4 (� Application Accepted by �l1 _.._.-_ Date i Area p Pit or Grout Inspection by / Date ]�1 Final Inspection by. t1 Date 3 O f Additional Comments: (r�� 8 ✓2-L L �i fly—$ ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ 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 CASH CK 0 RECEIVED 8Y DATE PERMIT'NO.. +.EH13441REV.iiHsY `�• ?� �� j/ EH 11- ,5 28 "� ,J (�`- C6 b