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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone 5209) 466-6781 %z;()py PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ICarnplete 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. 1852 for well/pump and the Rules and Regulations o1 the San Joaquin Local Health District. Job AddressO21449 I aCity Lot Size PM Li { Owner's Name tZt4erAddress '21443 wZ Phone Contractor&AY, 4 Address W „- License No 0/Q Phone TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR OTHi DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL 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 ❑ Gravel Pack © Tracy Type of Casing Specifications M Public n Other 11 Delta Depth of Grout Seal Type of Grout Irrigation ?—Approx. Depth l I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth f=iller Material (Below 501 _ TYPE OF SEPTIC RK: NEW INSTALLATION I 1 REPAIR/A ITION I I DESTRUCTION I (No septic system permitted if p tic sewer is 3 available within 200 feet Installation Installation will serve: ce Commercial_.._--. Other Number of living units- Number of bedrooms Character of soil a depth 3 feet: Water table dept SEPTIC TAN ❑ T Mfg Cap ity__- Na. Compa nts PKG. T MENT PLT. ❑ Method Disposal Distance nearest: �ell_ Foundation Property - e ; LEACHING LINE C( No. & gth lines I le h/size t FILTER BED ❑ ce to nea Well Foundation Property Line SEEPAGE PITS I I Depth Sire Nurii SUMPS ❑ Distance to nearest: Well Found Property Line DISPOSAL PONDS ❑ ✓� I hereby certify that t 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 Dittrict_ 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," ti .t The applicant c t f r all uired inspections. Complete drawing on reverse sid k Signed X Title:_ Date: a � FO ENT USE ONLY f Application Accepted by Date �'�� ,5 Area Pit or Grout Inspection by Date Final Inspection by_Jd eW4oat v- Additional Comments: ; ❑ Stk 4664MI ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑Tracy 8364385 Applicant- Return all copies to: Environmental Heatth Permit/Semi 1 1 5, sk_p696 t r FEE INFO OUNT DUE AMOUNT-REMITTED CASH RECEIVE eY pATE PERMIT'NO. a Eri1124{RE1r_r/as1 �� A�� 4 -L7� �• EH ltap +�