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�1e[. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I �'f �/ Job Address _—L3 1 L�tdh City Lot Size a-e- PM Owner's Name92elno d:k z Address /Q Phone -L®�_ Contractor Address Z 'Fe License No. Phone l6r Y�7 76 TYPE OF WELL/PUMP: NEW WELL iNELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ A�,,$YSTEM REPAIR L1 OTHER / DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINESIIG 0,,,,-//t DISPOSAL FLD.�� PROP. LINE FOUNDATION / AGRICULTURE WELL AML OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9, 42, Dia. of Well Casing o� ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing O Specifications FI Public 1-1 Other 171 Delta Depth of Grout Seal 1,5Type of Grout I i Irrigationut-_Approx. Depth ( I Eastern Surface Seal Instatled by Repair Work Done L7 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth (7` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( ) DESTRUCTION I I (No 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: 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 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number • SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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, 1 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 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 required inspections. Complete drawing on reverse side. Signed X Title: ,L(,C-L"-� Date: ��-2'�Ty FOR DEPARTMENT USE ONLY f/ J Application Accepted by Date W Area `!3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ,��r��+ Z /:2e- S. 4�E r7�� y� �p ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy/835-6385 Applicant - Return all copi s to: Rnvironmental HepIth Permit/Services 1601 E. Hazalton Ave., P.O. B x 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. + EH 13.21 fREV. /M5r , A £H U-28