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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA V 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 ,r Local Health District. l ' Job Address y City L�A Ir\ - Lot Size PM ' Owner's Name E LAD _A F Ift ' Phone "_.Cantra'ctor' Rddress"�- a �o--= 1 z. -License-No-- �a_. -Fhone-/d - - 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 _e OTHER WELL _ PITS/SUMPS Q� INTENDED USE 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p ❑ Industrial ;. L7 Open Bottom ❑ Manteca Dia. of Well Excavation # Dia. of Well Casing �} * Domestic/Private + ❑ Gravel Pack• ❑ Tracy Type of Casing Specifications F] Public F] Other,,A F1 Delta Depth of Grout Sea! 1 Type of Grout I I Irrigation i --Approx.' Depth i 1 Eastern Surface Seal Installed by l it Repair Work Done O Type of Pump H.P.- State Work pone i Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth } Filler-Material (Below 50') { TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION i I f DESTRUCTION septic system permitted if public sewer is ' t Installation will serve: Residence-I` Comavailable within 200 feet.) mercial— Other � 7 Number of living unists: Number of bedrooms Character of soil to a depth of 3 feet: t i Water ti ble depth SEPTIC TANK ❑. I Type/Mfg Capacity f � --- No. Compartments PKG. TREATMENT PLT- ❑ of Disposal I Method' i Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines + Total length/site ± f FILTER BED j ❑ Distance to nearest: .Well y t Foundation SProperty Line__ SEEPAGE PITS 1 ) Depth Size Number SUMPS f L1 Distance to nearest: Well t I Foundation Property Liner DISPOSAL PONDS I ❑ 1 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. I 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 certifiea 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 is s o iomia ' i The a ant us call for lire red ctio -�o to drawing o�eversesid ` Signed X_ _.Title: - £ .._ Date: r f FOR DEPARTMENT USE ONLY s Application Accepted by Date_ � 1 Area Pit or Grout lnspection by Date Final Inspection by Date / 9A ditional Comments::. Stk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104 ❑ Tracy 835-6385 plicant - Return alf copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE e AMOUNT DUE INFO ! AMOUNT MITtED CK RECEIVED PY DATEPERMIT'NO. CASH + EH 13-24(REV