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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT �C 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11,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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /` Job Address loaq �u�`—: - !`V City ! / Lot Size s PM Owner's Name/Jtph 1�— [r 1�i i;49 1� Address Phone Contractor LAWL01 Ca. Address 11174410 s1 cs License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WE' OTHER WELL—PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A C TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o ing Specifications M Public n Other ❑ Delta Depth of Grout Type of Grout I I Irrigation --Approx. Depth I I E ern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 �✓ Depth Filler Material (Below 50') G, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION)K INo septic system permitted if public sewer is y J available within 200 feet.) 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 , n PKG. TREATMENT PLT. ❑ Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 California." Theapplic ust call for II required inspections. Complete drawing on reverse side. Signed X Title: iLG w Date: (LA` 3411,,VA DERARTMENT USE ONLY Application Accepted by ,tj',t1s4 ,'` gmj�� Date Area Pit or Grout Inspection by Date Final Inspectio by i�/ LG-cCTM� Date Additional Comments: `J I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEGJAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.)i R 5) (© 3�. �/`\ \ 1 l - 1 g1-H a EH 14-Ze V ,w lJ