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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Local Health District. r 2 C _ t� �j - 1 �L Job Address f IZe l o�—`' City Ke t PL7"N Lot Size �� PM e � Owner's Name l(-'u �, /_G;,.- !s Address �/P,y,J Phone ContractorA. Lz H y!(.�(` Address ` T License No.. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER U DISTANCE TO;NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i-I Public U Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation ' _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. ' State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION X RLPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.( Installation will serve: Residence� Commercial_n Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SA'�dty,_ ,t}Jt^+� Water table depth SEPTIC TANK ❑ Type/Mfg -� L. Capacity��tzG No. Compartments - r• PKG. TREATMENT PLT. ❑ fT Method of�Disposal Distance to nearest: Well IeO Foundation -+ Property Line i r LEACHING LINE �^ No. & Length of lines �,76 y� '[oral length/size FT Fr F r ' FILTER BEDCl, Distance to nearest: Well_,160 Foundation.� Property Cl, _ �3 SEEPAGE.PITS; I I Depth Size _ Number SUMPS ❑ 'Distance to nearest: Well _ Foundation. Property Line DISPOSAL PONDS ❑ - 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 s 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 perionin-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, 1 shall employ persons subject to workman's compensa- tion laws of California.- The a alifornia."Thea licant -�- pp must call or all quirad inspections. Complete drawing on reverse side. p �1 Signed X� Title: 6( , , , Date: ••G�� /�/� FOR DEPARTMENT USE ONLY Application Accepted by 4 ,5�'z L" ` ._,. ._ Date Area Pit or Grout Inspection by Data Final Inspection by r• Additional Comments: ❑ Sill 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 „n Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE CK If - INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. .►11a.24(REV.11hs1 EX 14211 �/