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+ APPLICATION FOR PERMIT ��- PCt wit-E I I��g SAN JOAQUIN LOCAL.HEALTH DISTRICT ) € 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !k (Complete in Triplicate) fApplication 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. Job Address t City Ste _ Lot Size PM Owner's Name LLYYL 1j'1 J iVllt G�?"�' „ Address Phone �� t c'I Contractor +r1 '� LXL Address I ,.,.. — License No.-,0 3_2a;-Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r I SEWER LINES DISP7OSAL FLD. PROP. LINE a FOUNDATION AGRICULTURE WELLr OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing specifications FI Public ❑ 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. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is { t available within 200 feet.] Installation will serve: Residence A—� Commercial_ Other t -Number of living units: j Number of bedrooms Character of soil to a depth of 3 feet: I Ad t Water table depth '- SEPTIC TANK ❑ Type/Mfg �� ;P �, Capacity—A.._��6_._ No. Compartments PKG. TREATMENT PLT. ❑ i Method of disposal Distance to nearest: Well 0 Foundation Property Line LEACHING LINE 50 No. & Length of lines Total lengthlsize r FILTER BED ❑ Distance to nearest: Well ' _ Foundation b Property Line — I SEEPAGE PITS tM Depth Size 1n Cin, Number SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL. PONDS ❑ r 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. Home owner or licensed agent's signature certifies the following: + employ an "I certify that in the performance of the work for which this permit is issued, I shall no p Y y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signaetur 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 compe e tion laws of California." } The applicant must call for all re Y nspecti ns:Complete drawing on reverse side. _ Signed t Date_: �. ? 9 FOR DEPARTMENT USE ONLY - r F Application Accepted by Date Area ; Pit or Grout Inspection by I pate Final Inspection by l^ Date (�j� ,. Additional Comments: c c ` ��5 V`tV ❑ Silk 466-6781 ❑ Lodi 369-36,11 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmef ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 `� 1 4 FEE.: "AMOUNT REMITTED' CK _ — 3 INFO AMOUNT DUE CASH RIS VED Y� DATE PEHMIT'NO. +.EH 13-24(REV,I '15) 12 (61 U EH 14-26,,