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.tr rt APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �1 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. C �' Job Address Q a d13 ere t r .i> City F,�rCW of Size `• 3J. 0c, PM Owner's Name Ohl � �� Address �� L7�°I�i i� /�� Phone 3 7).J ;Contractor S'�✓� -� Address License No. Phone T�YPE,OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑.ti, PUMP INSTALLATION ❑ SYSTEM REPAIR .❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE _ FO NDATION � AGRICULTUpE WELL tl OTHER WELL PITS/SUMPS �y INTENDED USE TYPE OF WELL PROBLEM AREA" 0 STRUCTION SPECIFICATIONS ❑ Industrial L2 0, Bottom ...Ll Manteca, Dia. of Well Excavation, Dia. of Well Casing LJDomestic/Private ❑ Gravel Pack r` ❑ Tray Type of Casing Specifications o d M Public Cl Other t. ❑ pelta Depth of Grout Seal Type of Graut I I Irrigation Approx: Depth IFI Eastern Surface Seal Installed by — Y– Repair Work Done ❑ Typelof.Pump H,P, State Work Done ! Well Destruction ❑ Well;Diameter .-F Sealing Material trop 50'1 " Ri ' Depth.R° ,.. Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L1 DESTRUCTION I t'{No septic system permitted if public sewer is r r *" 'R ?available within 200 feet.) s installation will serve: Residence Commercial_ Other Number of living units: er of bedrooms �,-- ✓` e Character of soil to a depth of3 feet: _ Water table depth SEPTIC TANK. °` Type/Mfg - "�Capacify'+! )D No. Compartments .0 PKG. TREATMENT PLT. ❑ '' t,I I r - t I� Method of Disposal 1e lWe- Distance to nearest: Well /O Gti ; Foundation " Propert*''y.,Line– '57t.5–"i LEACHING LINE No. Length of Eines g Total length/size + FILTER BEb" ❑ Distance to nearest. Well OCA. (� j .yam , I� .�� Foundation c property Line SEEPAGE PITS I I Depth OZ Size Number SUMPS Distance to nearest: Well Foundation� _ property Line DISPOSAL 7•�'— PONDS ❑ I� �� c ,. F _ _ I hereby certify that I have prepared this application and thaVthe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sari Joaquin Local Health Di$trict. Home-owner or licensed agent'ssignature 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,:1 shall employ persons subject to workman's compensa- tion laws of California." 11. 'S A.4 „R 'r � ...rtrs a 1k aft 0+ The appfica call for all equired'nspe iia Complete d'rawing.on reverse side. g 1I. Signed Title: Date ' —4- R ARTPE ONLY "•+, Application Accepted b +' p Y 'h v Date �fJ� Area Pit or G nor SDate Final Inspection by, �� Date AdditionIERin.2.- 0 t Stk 466-6781 ❑ Lodi 1369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: IEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMgUNT REMITTED INFO C SH RE IVED BY GATE PERMIT'NO. y h . ll EH 14-28 !Iey C! _ II�