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I�li APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZEL T ON 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. r y� A y' Job Add ess G� ' i� u1N P a� City �'4C 41 Lot Size PM Owner's'Name /` L��s �r Address lav 151e.Vcl. 11 J57phone Contractor l {- aLM Address License No. Phone 4 TYPE Of; WELL/PUMP: NEW WELL WELL REPLACE ENT ❑ DESTRUCTION ❑ I' rt PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE I#" 1 FOUNDATION e/ AGRICULTURE WELL OTHER WELL PITS/SUMPS tT� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private PrGravell Pack ❑ Tracy Type of Casing_ / Specifications /610 f'1 Public Cl Other ❑ Delta Depth of Grout Seal S8` Type of Grout I I Irti ation T g .��2-Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump4 H.P. _ _ .,..__ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �Jy Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I.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 bedrooms 1 Character of soil to a depth of 3 feet:3 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance-to nearest: Well Foundation Property.Line k . 5 LEACHING LINE ❑ No._.&.,Length of linesTotal length/size FILTER BED ❑ Distance-to,nearest:Y�.Well _ Foundation Property Line ¢ .W SEEPAGE PITS I I Depth Size Number SUMPS1 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �.. I hereby;certify that I have piepared 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 Doltrict. - Home owner or licensed agent's•signat&6.certifies the following: "Icertify-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 law`s of California."Contractor's hiring or sub-contracting signature certifies 4he following: "I cartify that in the performance of the work for which tFiis=permit is issued,I shall7rrlpioy.persons subject to workman's compensa- tion laws of California." The applicant must call for equir din pecti ns. Complate_`drawing on'reverse'side" Signed Title: Date I4 FOR DEPARTM T USE ONLY Application Accepted by -------Date2-► Area Pit or Grout Inspection by Date 1 r 'f Final Inspection bDate ' Addition46 lll Comments: fi ❑ Stk 466-6781 ❑.Lodi- 369-3621 0 Manteca 823-7104 ❑ Tracy 635-6365 Applicant- Applicant to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 'FSE AMOUNT DUE AMOUNT REMITTED DK RECEIVED BY DATE PER IT' 13 INFO ,�+� lJ,{] /[ CASH MIT' EH 14-26 + LJ� !V V [ V a EH 13-24 1REV.W H 51 /t /�I p II. I