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:n APPLICATION FOR PERMIT n 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 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. Ot&,2 f 7 -7 1 �� Cit �- PM Job Address y Lot Size t Owner's Namew Address �LiLAL�I EPhone �i Contract r �L�!� L(`f i mac+ Address 1 0, < J901, License No. IG Phone- i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public f_l Other M Delta Depth of Grout Seal Type of Grout -- I I Irrigation —Approx. Depth t ) Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') +a t Depth ler Material (Below 50) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAI ADDITION W DESTRUCTION l 1 INo septic system permitted if public sewer is ,/ available within 200 feet.) Installation will serve: R�j'dence P / Commercial_ Other: f Number of living unit s: .,..L....._ Numberdroom Character of soil to a depth of 3 feet: �' _ Water table depth o SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to)nearest: Well Foundation Property Line LEACHING LINE Ce-_'No. & Length of tines �� , Total length/size FILTER BED ❑ Distance to nearest:' Well SO Foundation �C? Property Linesl .._. I rI id SEEPAGE PITS 1,r-'Depth 5 Size c3 Number SUMPS ❑ Distance to nearest: Well 100 Foundation 10 Property Line DISPOSAL PONDS - O 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 District. 1 Home owner or licensed agent's signature certifies the following: "I terrify 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 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 n f laws of California." w l The applicant call for eq 'ad inspections. Complete drawing on reverse side. Signed ✓ X Title: �/+ ` �- Date: F09 DEP RTMENT USE ONLY Application Accepted by / Date Area f Pit or Grout Inspection by Date Final Inspection by I/"&V-1 � Date Additional Comments: r- ❑ Stk 466-6781 ❑ 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 INFO AMOUNf DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-N0. E1i 13-24 fREV.I/H51 EH 14-26 LLLIII