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APPLICATION FOR PERMIT /V0 ' SAN JOAQUIN.LOCAL'HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., .STOCKTON, CA I Telephone(209? 466-fi781 I PERMIT EXPIRES .1 YEAR.FROM DATE ISSUED • , _,,(Complete,(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. ' t, LJobAddress City Lo Size 6PM er's Name k .= f r ��//�dr �e) A/C-'�~ W Phone tractor (� L ! Address License No. Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL RJL NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.F _DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL k' PRO BL AREA CO TRUCTION SPECIFICATIONS Ll Industrial Il Open Bottom ._ ElMantec I . of Well Excavation Dia. of Well Casing ,l. El Domestic/Private El Gravel Pack , ❑ Tracy Type of Casing Specifications I. ❑ Public ❑ Other elta Depth of.Grout Seal Type of Grout ❑ irrigation -1I�pprox. Depth LJ 'Eastern mace 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 507 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is IlI i- available within 200 feet.) Installation will serve: R idence Commercial— Other F Number of living units: Number of bedrooms ,I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑1. No. & Length of lines Total length/size f) FILTER SED LJ to nearest: Well Foundation Property Line � 7 SEEPAGE PITS-- ❑# Dept Size Number m SUMPS ❑I Distance.to nearest: well - Foundation eProperty Line DISPOSAL PONDS ❑ 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. 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." Contractors hiring 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." i The applicant Must call for all re fired inspections. Complete drawing on reverse side. i LCA/ Signed X Title: Date: FOR DEPARTMENT USE ONLY X11 Application Accepted by Date -�- �� Area v 9 Pit or Grout Inspection by Date Final Inspection by '' Q-- Date ` r7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 GK RECEIVED BY DATE PERMIT'N0, INFO GASH + EH13-24iREV.I/a5l .i _ � ( � /6 EH 14-26 . ll . _ ---