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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 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 L Local Health District. Job Address LAI �e..1 o y:�u Q_ City of Size PM i Owner's Name 11 1�(m1 0� i n ct C Address C <��n tl .n nPhone r SContractor \`I— Address License No._ —�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION II 1 _ 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 r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'] Public F1 Other ❑ 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. °f + State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Q , Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION I I DESTRUCTION A INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:I _ _ - Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments ' µ l PKG. TREATMENT PLT. ❑ Method of Disposal kk V Distance to nearest: Well Foundation Property Line E' LEACHING LINE ❑ No. & Lon gth of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS l I Depth I Size Number \ SUMPS Ll Distance to nearest: Well Foundation Property tine 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'D%i tricf' 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 of 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." The applicant must call for all squired inspections. Complete drawing on reverse side. " Signed � Title: ��1��cd_ .__ Date:— FOR DEP A TMENT USE ONLY Application Accepted by Date 'r Area Pit or Grout Inspection by Date Final Inspection by Data17 ' Additional Comments: 1 d . LI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 04 El Tracy 5-6385 J Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95241.FEE r I� INFO �AMOUNT DUE t /A7MOUNT�REMIITTT'ED CK CASH? RECEIVED BY DATE �+j cy PERMIT NO. +.EH 43-241REV.liHal C J I f' �6 S -1 EH 14-2e ✓ 110 VV IV J1 .�! / /c