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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin f Local Health District. Job Address ;k-Cl Z-C,4_mnLEO,f>G City �G Lot Size PM ,1 c� n Owner's Name . G/1 � N �iLQ'. Address �� " v ��u� Phone Contractor la� feya ' _ Address 3 a �` �� License No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR O OTHER fl DISTANCE TO NEAREST: SEPTIC TANK _�_ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA71NS �I ❑ Industrial .. Y ❑ Open Bottom ❑ Manteca Dia. of Well Excava n Dia. of Well Casi g omestic/Private Gravel Pack ❑.Tracy - Type of Casing Specifications 1 V 24Zi`. ❑ Public ❑ Other`— Cl Delta Depth of Grout Seal, a Type of Grout 1.3 Irrigation Approx. Depth I I Eastern Surface Seal Installed - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction . ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I i DESTRUCTION I 1 {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 !�yy Water table depth Character of soil to a depth of 3 feet: 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 17� 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 Di%trict. 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 h 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: 1 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 applicantd - spections. Complete drawing on se side. Signed X elf for all e rev Title: Date: FOR DEPARTMENT USE ONLY l Application Accepted by Date Area --r�L Pit or Grout Inspection by ate Final Inspection by Date ry 6 _ o Additional Comment iV�vim" Z3— _ Stk 466-678f Lodi 369-3fi21 '1-] Manteca 823-7104 CI Tracy 835-6385 Applicant- Return all opies o: Environmental Health Permit/Services 1601 E. Hazelton:Ave., P.O. Box 2009;Stk., CA 95201 FEE AMOUNT DUE AMOUNT.REMITT£D CK 4 CASH HECEtVED BY DATE PERMIT'NO. INFO ` ' ?EH 3-2A[FEV.t/x51 EH 114-2a