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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA tw I Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED i (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. f� ,,1 t ` I Job Address —_-LA! W e_ i U Ir W e-V, d y T - City L Lot Size Ply Owner's Name �� S L�V�1� 1 ess dX1:133 Phor>� Contractor f f �//� Adtlres License No�2 Phop-fr TYPE OF WELL/PUMP: N- WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Nlvni�Cx1 �� Z� PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER CJI DISTANCE TO NEAREST: SEPTIC TANK ,.., r1 I SEWER LINES 60 " C "_ DISPOSAL FED. 50' PROP. LINE �d0 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2tj tail rr� ❑ Industrial ❑ Oen Bottom 1-1 Manteca Dia. of Well E anon �y Dia. of Well Casing "1 ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing fv� 5pecifications `� f"1 Public ❑ Other e Cl Delta Depth of Grout Seal __-lett � Type of Grout+-142 I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Dustuction ❑ Well Diameter Sealing Material (top 50'1 IMd1�1C�OG^R N x Depth Filler Material (Below 501 OF SEPTIC RK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ce_ Commercial_ Other Number of living units: Num bedrooms Character of soil to a depth of 3 feet: I Water table depth ; SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line /� lL LEACHING LINE ❑ No. & Length of lines Total lengt 61; FILTER BED ❑ Distance to nearest: Well Foundation Property Lin SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line V► `DISPOSAL PONDS 0 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 Joaquin1ocal Health District. 0 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 laws of California."Contractor's hiring or sub-contracting signature V 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." r The applican ust all for requi ins ction omplete drawing on reverse side. Signed X - Title: Date: 2 8 FOR DEPARTMEN USE ONLY Application Accepted by Date Pit or Grout inspection by ate nal Inspection b Additional Comments: ❑ Stk, 46676781 ❑ 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 AMOUNT DUE AMOUNT REMITTED I CCK* RECEIVED BY DATE PER N0. I INFO +.EH13-241REV.t/x5) .U� EH 14-28 1 �r ^- �q _y C]7 - 1 - ii�