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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 486 M1 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 Ryies and Regulations of the San Joaquin Local Health District. Job Address 2'7 City Lot SizeQQ_c_Lt_ASt.A.,+ PM Owner's Name Address �L.. . Phone UV Contract Address 0License No;��Phon S Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION d SYSTEM REPAIR ❑ OTHER ❑ 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 y O Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` \ G Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth D Eastern Surface Seal Installed by —Repair Work Done• -L]-.-Type of Pump -- H.P. - • - State Work Done Well Destruction ❑ Well Diameter Sealing-Material atop 50'1 ' Depth "r: + t �� 'ler Material (Below 501,t= / ! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ leEPAIR ADDITION TDESTRUCTION ❑ (No septic system permitted if public sewer is- - s es- r ' --available within 200 feet.) Installation will serve: Residence Commercial_ Other f Number of living units:I Number of bed ms � r Character of soil to a depth of 3 feet: _Water tabie depth SEPTIC TANK ❑ Type/Mfg Capacity—�"'No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line ! 1 LEACHING UNE *-_`No. & Length of lines '- Total length/size Q d FILTER BED ❑ Distance to nearest: Well Foundation r1 d Propertya_Une SEEPAGE PiTS ❑ Depth Size _ Number SUMPS LAI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS :J -� a 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, 1 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,f shall employ persons subject to workman's compensa- tion laws of California." The applicant st tail for req 'red inspections. Complete drawing on reverse side. - Q AlSigned ��`� -9— Title:_ _ Date:A �•�- r1 S a FOR PEPARTIVII T USE ONLY Application Accepted byP Date Area V� Pit or Grout Inspection by Date Final Inspection by Additional Comments: 01 _ ❑ Stk 466-6781 ❑ Lodi 369-3621 D 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 4 AMOUNT DUE AMOUNT REMITTED CK 0 INFO CASH RECEIVED BY DATE PERMIT NO. + 14-EH24(REV.ti65} F3i t4 ?a (/