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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ITelephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. Job Address yA[X,lT �. �¢i(Cj� E�� Lot SizePM Owner's Name z LCiY%y� Address 1Fa N%%:�lF�t/ Phone Contractorr Address TYPEFCrt/e� o_ Phon 2 � OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ITONEA C TANPUMP INSTALLATION ❑ SYSTEM REPAIR E) OTHER [IDITANCE SK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS _ Industrial ❑ Open.Bottom ❑ Manteca Dia. o vation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑Public ❑ Other ❑ Delta Depth of Grout Seal, e of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction El Well Diameter _ Sealing.Material (top 50') ,t Depth ' Filler Material (Below 50') c}l TYPE OF SEPTIC WORK: NEW INS ALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sower is - available within 200 feet.) Installation will serve; Residence Commercial__ that "W$' Nurn6er of fivirrg units: Num of bedr p� Character of soil to a depth of 3 feet- %. / Water table depth SEPTIC TANK ❑ Type/Mfg �,crleilr r Capacity / �o. Compartments PKG. TREATMENT PLT. L3Method of Disposal Distance to nearest: t Well Foundation Property Line LEACHING LINE o. 8 Length of fines Total length/size r FILTER BED ❑ Distance to nearest: eRFoundation_ pope ty L rte LAI SEEPAGE PITS e--f5 � S epth — Lize U Number SUMPS ❑ Distance to nearest: Well Foundation j�O �f'rapertv Line �pfQ DISPOSAL PONDS ❑ I hereby certify that I have Prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pemat is issued, I shall not employ any Person in such manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub so signature certifies o following:"1 certify that in the perfomrance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California.- C The coil for n \1R'T�s�� r Complete drawing on reverse side. (�+� Signed�pK \sC /icy �L��TiOe: �$%�/,/,z' _ _ Date: _ alv/ tlr FOR DEPARTMENT USE ONLY � Area Application Accepted by v l-snU^� Date !Ilay —1 r 1 ` Oma. Pit or Grout Inspection by/ nn '/ ate I - I Inspection Additional Comments: G W ( Ot'�-� '- ❑ Stk 466-6781 ❑ Lodi 33821 ❑ Manteca 7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE MOUNT;!A'l D K RECEIVED BY DATE PERMIT NO. y■� INFO .•^/I ✓J /`_ /y'�/O / C`Jf !/ _) 1