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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT U 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 IY / Aen�� :, Cit Lot Size_ � � PM Owner's Name L, U LJ Address Phone Contractor rt L CDUS (Address S 0 UJI' C l License No.14 3od`• Phone rJ �— 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing v ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("1 Public n Other F1 Delta Depth of Grout Seal Type of Grout I i Irrigation �._Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ _ 1 � Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION ESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re idence Commercial_ Qther Number of living units: 77 Number of bedrooms Character of soil to a depth of 3 feet: Z d Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well. Foundation Property Line LEACHING LINE &+—'I o. & Length.of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line' SEEPAGE PITS 1,L epth Size _— Number SUMPS LI Distance to net: Well Foundation__ Property Line DISPOSAL PONDS 17 a sU\ L RA E 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, 1 shall employ persons subject to workman's compensa- tion a California.' Theapplicant all for all quir ins�io a drawing on revs a side. Signed X itle: ( � ~y%� � Date: /,a r �V FOR DEPARTMENT USE ONLY u Application Accepted by Date ` , S' Area 4 Pit or Grout Inspection by Date y J� �/ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 E'r/jt if r-ealra rnt n 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 CASHCK 11:- RECEIVED BY DATE PERMIT NO. . EH1341(REV.r i w 51 _ [w— 4 u EH 1148. I"•� f