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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. I-IAZELTON AVE., STOCKTON, CA Tefephohe (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 Jod_quin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I C t/ p' J46 Address .< ✓/� J� "7A, ity �G� ,1� Lot Size 015 p(VIW. Owner's Name i ('.t71�f�^l PICI��AddressS , T /f_.�^� Phone O Z Y' P�.4 Y�I LU +�G //ll rfG �. - -� - Contractor ( � Address�6�1( •��` License Na. Phone SZS7o TYPE OF WELL/PUMP: �i! NEW WELL El WELL REPLACEMENT El DESTRUCTION Llp 2 PUMPI,INSTALLATION ❑ SYSTEM REPAIR ❑ OTH�E � 5 � D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P OP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open.Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 3 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public F. Ottier ❑ Delta Depth of Grout Seal Type of Grout 1 _ 1.1 Irrigation Approx. Depth -_I J Eastern y Surface Seal Installed-by Repair Work Done ❑ Type ft Pump H.P. " -State Woik Done' al e Well Destruction ❑ Well Diameter Scaling Material (top 501 y Depthl� Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION I 1 INo septic system permitted if public sewer is Iavailable 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 i x " ' Di&nce'to nearest: Well Foundation '� Property Line i ,r LEACHING LINE ❑ No & Length of lines �' Total length/size f FILTER BED ❑ Di(lance to nearest:/. Well Foundation Property Line i f SEEPAGE PITS (_I_ Depth -Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ M 4 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 f? 4 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 laws of California,"Contractors hiring or sub-contracting signature n certifies the following: "I certify tAat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- _V lion laws of California." 110 -The applica must I a=eirnd inspections. Complete drawing on reverse side. �(Sjgned X Title: _ Date, �Z g� F R DEPARTMENT USE ONLY a� , / Application Accepted by LLS Date Pit or Grout Inspection by �! Date �— Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 . -0 Tracy= 8355-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE t i "INFO MOUNT�DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT'NO. + EH 13-2 (REV. EH 14-2e i i K 51 ,5 riD