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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 00py (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. 1962 for well/pump and the Rules and Regulations of the San Joaquin j Local Health District.- Job Address 1Ly,�jO •6�Jt 1 , city Lomat Size PM - ' Owner's Name Address 7 Al, /gyp . Phone /0 AN I Contract aY a Address��a�,c 7�7_,-..GC.pt� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION. ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .FLO. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done_ 'Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 'Iter Material IBM=501 .TYPE OF SEPTIC WORK: NEW INSTALLATION 0EPAI ADDITION P�' DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serge. 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 Distance to nearest: _. Well Foundation . Property Line f 1 i. LEACHING LINE re No. & Length of lines _(=� _ Total tength/size O K FILTER BED ❑ Distance to nearest: Well ��D ` Foundation `. /L] Property Line I r SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well �60 .Foundation /O` Pro � party Line _-,_ DISPOSAL PONDS ❑ I he 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 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."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 laws of California. The applican ust call fo all required inspections. Complete drawing on reverse side. Signed ` A Title: s �� Date: b 1p FOR DEPARTMENT USE ONLY Application Accepted b.y Date-q-- Area r 6itr Grout Inspection by Date final Inspection by Date Additional Comments: ❑ Stk 466-6791 ❑ 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 CK RECEIVED 6Y I INFO CASH DATE PERMIT N0. + E14- �0 241REV.�/851 ,�(� 11 EH 14-26 . rrr R70 1 V w