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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEL—PON AVE., STOC}KTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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.sewpge or No. 1862 for`well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address LcJ 1 Z-- ' City Lot Size «' pM #" Owner's Na ` ® Address 0 Phone Contractor's Name C License No. - 3 , Phone 36,F~ 31 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK: SEWER LINES I DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELLI OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA: SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavaiion Dia. of Well Casing C) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'k Specifications r,] ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout V' ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ ,Type of PumpH.P. "i, "State Work Dohe Well Destruction ❑ r:Well Diameter Sealind Material'(top 501 Depths t Filler-Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L2'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �._ available within 200 feet.) [ Installation will serve: Residence " "Commercial_ Other "# Number of living units: Number o edrooms� I Character of soil to a•depth of 3 feet: A J ! Water table depth SEPTIC TANK _ L—Type/Mfg 444;,,64- opacity 12Zi2 No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of D`�pqsal yam , 4 1 1 Distance to nearest: Well :Foundation�� Property Line LEACHING LINE 0—No. & Length of lines Ili Total length/size FILTER BED 'Distance to nearest: Well Kra Foundations_ property Line O # SEEPAGE PITS ❑ Depth _�d Size r LJ, <r� �� Numbrrer�� SUMPS Distance to nearest: ` Well� Foundation 3LProperty Line DISPOSAL PONDS'-" ❑- I hereby cert!N that I have prepared this application and that the work-will-be done-in accorl ance 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-iawsof 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 Prior all ire inspections. Comp!ete drawing on averse side. Signedy�9� Title:' - doeel '"� Date: 'FOR DEPARTMENT USE ONLY p Application Accepted by `Date — -�d•� Area Pit or Grout Inspection by Date Final fnspectian by LL pie Additional Comments: �- � :-,.-A , j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 X6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ei �i FEE gMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"N0. INFO CASH j +EH 1324{REV.101831 �{ - }� {} EH 1428 - t S td f ��,. {/ p Li 7-1A '7