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. � I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (200) 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 th work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump kte Rules and Regulations of the San Joaquin Local Health District. Job Address !/ - Cit t Size PM Owner's Na ddress one 1e / 7 lei- Contra Contra ta199i -`�-� (L_.► Address +il License Nam! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER / DISTANCE TO NEAREST: SEPTIC TANK 7 A�WER LINES ' DISPOSAL F . .ROP. LINE ? I FOUNDATION AGRICULTURE WELL 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 ,�mestic/Private ❑ Gravel Pack ❑ Tracy Type of,Casing ` Specifications ❑ Public ❑ Other EJ Delta Depth ype of Grout Seal T , , of Grout ❑ irrigation --Approx. b P E}"Eastern �ue..L�Se I {sta by /Repair Work Done ❑ Type of Pump H.P. State Work Dane { Well Destruction ❑ Well Diameter. - Sealing Material [top 501 Depth Filler Material f8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I tI t. available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other IJ . - i - Number of living units: Number of bedrooms ,ffa. „j �i e i Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity f t No. Compartments PKG. TREATMENT PLT. ❑ v ` 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 SEEPAGE PITS ❑ Depih Size i Number. ' SUMPS t ❑ Distance to nearest: "Well Foundations Property Line DISPOSAL PONDS ❑ I hereby certify'.hat 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 i 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 Lfollgv ing:"I certify that in the performa a of the . ork for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of'Cal' rnia." The applica t call for al squired ins ti s: Co a drawingon a side. Signed Title: Date-VJc'.�6 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date LC°/ TT - •" Additional Comments: i ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. ` + EH1 3-241REY.1/115) EH t428 I