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i T APPLICATION FOR PERMIT r _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Sari 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. l �- Job Address ` -. u u u r City LL_— Lot Size om2 o PM Owner's Name U __. Addressr Phone � i t .Contractor-wRL RL-�_ S�Adjress � = �=�--P. License No. Phone TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT 71DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -_- PROP. LINE _— FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUETI ON'.SPECIFICATIONS_ ❑ Industrial " C Open Bottom ❑ Manteca Dia. of Well Excavation_-. ` Dia. of Well Casing ._ 0 Domestic/PrMate o-U Gravel Pack ❑ Tracy o ype of Casing_-_I �'r__ Specifications 1 Public I / n Other { F.1 Delta -� I 3`Depth of Grout Seal Type of Grout JJ ( r f J r I I Irrigations _Approx. Depth I Eastern Surface Seal Installed byf-t _ - Repair Work Done ❑ Type of Pump __ H.P. ___ t State Work Done Well Destruction L1 Well Diameter _. ? Sealing Material (top 501 + Depth I Filler Material IBolow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION li REPAIR/ADDITION I i TRUCTION f 1No septic system permitted if public sewer is w r. Y available within 200 feet.) Installation will serve: Re ;dance Commercial Other I i` Number of living units: Number n bedrooms v} ' + i Character of sail to a depth of 3 feet: _ .-- __. -. Water table depth SEPTIC TANK ❑ Type/Mfg ( Capacity L—=44 No. Compartments PKG. TREATMENT PLT. I-1 } \A. �Method of Disposal s Distance to nearest: ! Well Foundation _ Property Line LEACHING LINE L-1 No. & Length otiines' 1c - I Total length/size _— a FILTER f3E0 [7 Distance to nearest: �'VIlell �-- ""-'Fb-GndaTion'"^ - Property Line SEEPAGE PITS C I Depth _- -_ S Siie__ - ; Number ' �� r- SUMPS ;stance to nearest: Weil^-z Foundation Property Line _ .) DISPOSAL PONDS ❑ K ! t r hereby certify that I have prepared this application and'that the work will be done in acEordance 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 (ollowing: "•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 id workman's compensation laws of 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 of Californ' r '�"""� i The applican st call f art r quir i ate drawing on r verse sid . 7 Y 1 j ._ Title: Date: Signe � __ j F OR DEPARTMENT USE ONLY 1 i � 1 e ` Application Acceptod,b —+ - I t Date `� Area _ p Pit orG out Inspection y _ Date 7-7—?l Final Fnspection'by Date Additional Comments: D Stk 466-6781 C Lodi 369-3621 0 Manteca 823-7104 n Tracy 835-6385 i 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 CK { RECEIVED BY DATE PERMIT NO. INFO CASH . EH13-24 IREV. 4-26i N 61 lO 7 EH • _ a 1