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+ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA a 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 Local Health District. Job Address CityMA Lot Size pM Owner's Name Address Phone ~� Contractor- _ LELF_ Address License No. ✓ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ `OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing .:Specifications ❑ Public n Other ❑ Delta iDepth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal_Installed by Repair Work Done ❑ Type of Pump H.P. State Work bone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') r TYPE'OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR'/ADDITION I 1 DESTRUCTION fNo septic 'system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 1 Number of living units: Number of bedrooms f r Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ~❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I 1 Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property 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 she 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 car tifies 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 it requir inspeff ions. mplete drawing on reverse side. Signed X 1 Title: Atoklbr. CX.11QQL,) Date: FOR DEPARTMENT USE ONLY_ Application Accepted by DateArea L Pit or Grout Inspection by Data Final inspection byF514 Date g ` UA ditional Comments: f Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 pplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK -215 INFO RECEIVED BY DATE PERMIT N0. + EH 13-24 0tEV. /K51 EH 14-2e y