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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone ('209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is 7 made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. Job Address 4 0 j -41<'—' City Lot Size PM Owner's Name Y Ye 5 r AddressniiiPZ Phone IqContract r 1 LJL Address Q Z License No.1hZ ?, Phone TYPE OF WELL/PUMP: NEW WELL G WELL-REPLACEMENT V DESTRUCTION ❑ PUMP INSTALLATION *-" SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �d,^�" SEWER LINES _ ' DISPOSAL FLD. SO � PROP. LINE FOUNDATION �_ AGRICULTURE WELL OTHER WELL ..O r PITS/SUMPS INTENDED USE TYPE OF WELL,t PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ O1. p Bottom- ,❑ Manteca Dia. of Well Excavation.. ._ Dia.'of Well Casing ❑ Domestic/Private ravel Pack ❑ Tracy., - Type of Casin V ` g- cifications (l Public C1 011 C] Delta ' Depth'of Grout Seal- ype of Grout�e1� �rigation pprox. Depth I i Eastern r Surface Seal Installed by f Repair Work Done ❑ Type of Pum P Yp p '-` H.P:' Is " "'State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') t Depth Filler Materia! {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 {No septic'system• ermated if public sewer is available within 2 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 i PKG. TREATMENT PLT. ❑ Method of Disposal -- Distance to nearest: Well F `Foundation Property Line r LEACHING LINE f ❑ No. & Length of lines Total length/size FILTER BED E) Distance to nearest: Well 'Foundation Property Line . : r SEEPAGE PITS I i Depth Siie Number SUMPS 1-1 Distance to nearest: 'Will a 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 1aws, and rules and regulations of the San Joaquin Local Health Dittrict. c , 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 perso ' uc 1 m ter as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting`sig`nature certifies the fell ing: "I certify t t in the perfor nce o work for which this permit is issued, I shall employ P p y persons subject to workman's compensa- tion laws of 'if The applica must c fo quired i let drawing on r side. Signed X Title: � Date: 1 FOR'DEPARTAAENT USE ONLY — % vi Application Accepted by Date "V i Area Pit or rout 1 spection byg Date ✓` Final Inspec-on by Date Additional Comments: P` I v 44 �'��C �/�/� Z S ?r/G � 1-1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 11Ak � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT N0. + 1 13-24 11 1/m 51 114-26