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� I APPLICATION FOR PERMIT 1/ 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) 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 ��© City _ Lot Size CY EZ.c PM Owner's Name f Address .Phone r Contractor `YLCi LLt� G Address License No. Phone p� TYPE OF WELL/ NEW WELL- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKn SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _pia AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MI Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Private 1 Gravel Pack ❑ Tracy Type of Casing 1? Specifications 1 Public El Other ❑ Delta Depth of Grout Seal dr T r Type of Grout Ll Irrigation Jca__ 4pprox. DepthALI Eastern S e Sea I tailed by !� --L. A< l n Repair Work Done ❑ Type of Pump 3 H.P. State Work Done_ v Well Destruction ❑ Well Diameter Sealing erial (top 501 Depth Filler Material (Below 501) ` TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V Installation will serve: Residence_ Commercial_ Other available within 200 feet.) 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 � PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lime SEEPAGE PITS ❑ Depth - Size Number �- SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r� 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 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 Calif ia." The cant mu call for all requod i pectio Complete drawing on reverse side. Signed X Title: ?—e P S Date: Z2f FOR DEPAR ENT USE ONLY \_ / Application Accepted by Date- 1.2 �J Area ! i Pit or Grout Inspection by Date a�� JFinal Inspection by a 41n, Date� 85 Additional Comment / 7G2I1G � ' Ol71-5cp—A ❑ Stk 466-6781 ❑ Lodi 369 1 anteca 823-7104racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE �PERMWNO. INFO CASH+ EH 13-241REV.tiH51 �� y/� EH 1 -28 ,v j/