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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Joh Address V 7 3 Won-do City %G Lot Size " PM Owner's Name ( h n t°`P.t F"f ra Address Phone i Contractor LV_C_ Address 19,01, �+ cb License Ko.c Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i 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 CONSTRiJGTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - - Did: of Well Casin y' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of-Casing - Specifications -1 Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx,.-Depth I I Eastern •= Surface Seal Installed by Repair Work Done L11'. Type,of Pump_< .•r„M;.H.P., 9 State Work Done Well Destruction O Well Diameter Sealing Material [top 501 f {r y Depth i Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is :available within 200 feet.) f" i Installation will serve: Residence— Commercial_ Other Number of living units: `+ Number of bedrooms `" I Character of.soil toaeptFi of 3 feed Q� - - — - - - } Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ll Method of Disposal i Distance to nearest: Well Foundation Property Line 1 LEACHING LINE CI No. & Length of lines Tfatal length/size FILTER BED Distance to nearest: Well �4Foundation Property tine S SEEPAGE PITS I 1 Depth Size _ Number r I SUMPS f 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%trict. ' r �; - ----- " 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;became subject to workman's compensation laws of California." Coniractor's hir'ing'-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." a The applicant m st call fo all iequ'ad inspections. Complefe drawing on reverse side: r f fj Signed Title: L&^ .�- ' Date: - i ' •'" FOR DEPARTMENT USE ONLY Application Accepted by _ lVl µ Date Area Pit or Grout Inspection by Date Final Inspection by Date k 1 y Additional Comments: ❑ Stk--466-$781__,_D-Lodi-364-3621-i.--EI Manteca 823-7104 -- ❑-Trac -'-�- --- - - ----- Y•-835-6385.-...+-^�.--d-_-w-.-.,..,- .--. . .. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l FEEi INFO AMOUNT DUE AMOU REMITTED CK 'R IVED BY �D TE PERMIT"NO. rEH13-24(REV.tiKSI �K Il / /0� /D EH a-26