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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. 1 1L� C Job Address 1. 1 1 ` G R`�I l Li E TZ City ` Lot Size PM Owner's Name �I\ ELL ) Address Phone Contractor WOLA L L Address License No. TCS a Phone S TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 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 CONSTRUCTION SPECIFICATIONS Cl Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications Ul Public 0 Other 0 Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IkLAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence L--c-ommercial_ Other Number of living units: Number of eddC�rrooms 3 Character of soil to a depth of 3 feet M Snyz t7� — C .[ —� ,��—Water table depth SEPTIC TANK 0 Type/Mfg C n t J C r� Cap ity v o. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well �� Foundation Property Liney LEACHING LINE M--.Wo. 8 Length of lines Total length/size ID FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ii J,-Depth _Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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. 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 - camAlits 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 California." Tlge> s call or II re rire`% c fl7_Jc7Rl,�)te drawingo arse si Si nedp y l Title: Date: r FOR DEPARTMENT USE ONLY rM Application Accepted by ,ter U1ti Data C "' � Area Q1 Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments: rStk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 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 PERMIYNO. INFO yy CASH RECEIVED q J �] ER 13.31(REV.rix Sr UA- EM 1FM /NL- II'a✓t.R-)