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1r APPLICATION FOR PERMIT F � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA Telephone (209) 466-6781 r 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 � ;o City Lot Size r PM Owner's Name Address 121wPhone f Contractor, 1by LCA Address License No. Phone 136 .3.3 € TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ NPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q y(✓ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0•Industrial ❑ Open Bottom ❑ Manteca ,�Dia. of Well Excavation Dia. of Well Casing, I ❑ Dornesflc/Private ❑ Gravel Pack LlTracy Type of'Casing Specifications ' i`l Public El Other ❑ Delta Depth oflGrout Seal Type of Grout I 1 1 Irrigation _Approx. Depth k Eastern (Surface Seal Installed by Repair Wark Done ❑ Type of Pump H.P. �/ 0n State Work Done _ Well Destruction Q Well Diameter /Sealing Material (top0501 -- 5 i1f I Depth Filler Material fBe10 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION 11 ✓REPAIR/ADDIrtJON DESTRUCTION I I INo septic system permitted if public sewer is �\ available within 200 feet.► Y� Installation will serve: Residence Commercial er — Oth Number of livingunits: A— Number of bed ro ms _ N Character of soto a depth of 3 feet; rte___ Water table depth a I SEPTIC TANK �`)❑i Type/Mf '� i- �/ UD 1 # Type/Mfg Capacity-_....L-cam.__ No. Compa+�tm�rits PKG. TREATMENT PLT. // 1 r Method of Disposal Distance to nearest: Well i i 1 Foundation Property Line,—,& LEACHING LINE �41VO. & Length of lines 's �� Total length sizes FILTER BED ❑ Distancgi0o nearest: W 11 Foundatif Property Line SEEPAGE(PITS I Depth 5�_0r) Size F/13 r `b Number f lur SUMPS i l Distance to nearest.- Well�n��..__ Foundation 17Si Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San'Joaquincounty ordinances, state laws, and rules and�regu la lions of the San Joaquin Local Health Dr"strict'. Home owner or licensed agent's signature certifies the followirig: "k.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 saffxcr"to Tia'87irfiian's compensation laws of California." Contract__or�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 taws sof California. IAn The applicant must call for all requireonspqrions. Complete drawing on reverse side. �. l 4 i r Signed X. Title: —D�.(!"L i ._ Date: .-- i 's f" FOR DEPARTMENT USE ONLY "� 3 Applicati in Accepted by Date 'JNArea) Pit or Grout Inspection by Date Final Inspection by Dalt. Additional Comments: 1 r t ' ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104"`" `racy;`835-685 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 CK 4 CASH RECEIVED BY DATE PER NO, ♦.EH 13,24%iREV.4ii1isy EH 14-20