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, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT cen6&lmoll 1601 E. HAZELTON AVE., STOCKTON, CA �d � Telephone (209) 456-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDf/ {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./ Q t�J�y Job Address �° " � Cityl r k- Lot Size PM Owners Name Lue1•A z vy�i�� Address ��/ �^%��+"z lJOUPhone d9 57eS, tSg.A Contractor e-ff Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR El 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _.Approx. Depth I I Eastern 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIWADDITION I ) DESTRUCTION iNo septic system permitted if public sewer is w available within 200 feet.) Installation will serve: Residence��t� O __E D O Number of living units: mbar o b Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ! Avg ftof f 6i it:uF No. Compartments w PKG. TREATMENT PLT. ❑ WOr #f comptrwl6d p } Method of Disposal /Q Distance as WeEI G1 tf ounZ7�td}fl�' Property Line �`L� b]fv i9flea1 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 Di"strict. 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^t 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.' The a 11 for eq ed spections. Complete drawing on reverse side. / Signe Title: Date:A FOR DEPARTMENT USE ONLY Application Accepted by � � Date S Q Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71134 ❑ Tracy 835-6385 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 CASH CK RECEIVED BY DATE PERMI'r'NO. +-EH 13-241REV.vH5) EH 14-26