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APPLICATION FOR PERMIT r ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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. `` c Job Address 1f cl�� t,,ub 1 e�� - City J Lot Size PM Owner's Name N\(21f_ Address 16)_ W ,^ �2 Phone Contractor_`MN La�N L_u _-V ass 1JlJ J icense No. LA OU'l Phone_ TYPE_DF 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 r ❑ Industrial.` Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack .. "❑ Tracy Type of Casing Specifications Fl Public Cl ❑ Delta Depth of Grout Seal Type of Grout _, LA i I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ 'Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR)ADDITION fit�`fRUCTION I I Mo septic system permitted if public sewer is f available within 200 feet.) G Installation will serve: Residence !=- Commercial= Other ,--"— Number of living units: —I— Number of bedrooms_ -j 1 Character of soil to a depth of.3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg a Capacity No. Corrtpartments PKG.-TREATMENT PLT ❑ Method of Disposal--- Distance to nearest: t Well Foundation Property Line LEACHING LINE Lq� & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well LX Foundation ,_ Property Line i SEEPAGE PITS ft.i_Depth e _Size Number SUMPS L] Distance to nearest: Well Foundation Property Line: I 0 DISPOSAL PONDS Cl 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 erson in suc anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the wing: "I ce 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 Cali ia." T applicant ust c for all re ired to dr g on ;envarsa side.Signed t e: ' t Date: / f j t 'i FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspecti Date Final Inspection by e Date Additional Comments: l - TL ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy -6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II FEE AMOUNT DUE AMOUNT REMITTED. RECK d CEIVED BY DATE T PEHMiT NO T INFO C S;I,'• a li + fEH124(REV.1/0 5) r- 1'�� ,P735/ k r