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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. C .Job Address _�7�1P� lC.LA+ ✓AI ^t^iy City � Lot Size PM G _ Owner's Name ,, !! Il N Al If S ULI �iAress ��/2)X_ Phone �— _ Contractor KAddress �� S /1 14 iN r License No��,r�Phone TYPE OF WELLMUMN - NEW<WELL 0 WELL REPLACEMENT ❑ DESTRUCTION C1 PUMP INSTALLATION f7 SYSTEM REPAIR.0 _ OTHER n DISTANCE TO NEARE3Ti SEPTIC TANK SEWER LINES _y — DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (1 Industrial Cl Open Bottom O Manteca Die. of Well Excavation_ _ Dia. of Well Casing I I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I I Public n Other LI Delta Depth of Grout Seal Type of Grout Mr frigation ___ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 64o' Type of Pump s LL H.P. �_ .�- State Work Donal-N-1&RU 41Well Destruction Ll Well Diameter Sealing Matbrial (top 501 S��L Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will se&b! Residence___- Commercial---- Other Number of living units: ___— Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK f 1 Type/Mfg _ Capacity__ No. Compartments PKG, TREATMENT PLT. (_l Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS I I Depth Size Number SUMPS I 1 Distance to hearest: Well _ F6undatlon Property Line DISPOSAL PONDS O I hereby certify that 1 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: "1 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, I shall employ persons subject to workman's compensa tion laws of California." The applicant m 1 for all r ired i pections. Complete drawing own reverse side. '' Signed X_ / _ Title: � - Date: 2 _9 r FOR DEPARTMENT USE ONLY Application Accepted by _ Date Afly - • � /9` Pit or Grout Inspection by Date. Final Inspection by Additional Comments: _ ( 1 Stk 466 6781 U Lodi 369-3621 [.l Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hatelton Ave., P.O..Box 2009, Stk., CA 95201 j , F FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. 114 1114(REV 1-� 5'Dv 7S 111 M J 11