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%W APPLICATION FOR PERMIT litim/ 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Q � �,j�/J /y�� Job Address SQL-/OD �� `-^""' `�'�' ' "' City Lot Size PM Owner's Name-r/-,/ fn�H'r` Address l- fe'11 91l Is,�. Phone Contract Ce Address Pc License NO. 2 7,� Phone• d!� -S , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other / Number of living units: � Number of oms s� D ! Character of soil to a depth of 3 feet: Water table depth T SEPTIC TANK 111- Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: W Foundation ��1 ProLiner A mac— party p �l LEACHING LINE G✓No. & Length of lines — Total length/size :r © kr� FILTER BED ❑ Distance to nearest: Well�� Foundation r Pro a —� perry Line-.-y�_ SEEPAGE PITS A"Depth C Size Number r SUMPS ❑ Distance to nearest: Well�� Foundation /A Property Line 7.S DISPOSAL PONDS Cl 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 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 laws of California." The applicant mus II for all regEri?pd in pections. Complete drawing on reverse side. ''1 q' Signed X JJ Title: V Date: ��l d�C-1 / FOR DEPARTMENT USE ONLY Application Accepted byd7 ,r• A Date Pi or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 WFO AMOUNT DUE AMOUNT REM ED I LASH RECEIVED BY DATE PERMIT NO. r EHt3-NIaFV.lixsl EH 1I-Za