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NN 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 ' * l (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/ppm d the Rules and Regulations of the San Joaquin Local Health District. /f1J�c� Al, `,,J „ ��}} cxr'vv1 LOPM %09, Job AddreWQ_6 Si It City t Vb _,.._ Lot Size LOPMOwner'sName ` �•��' - Address , iPhone Contractor's Name License No. + T « Phone TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ # DESTRUCTION ❑ 1 PUMP.INSTALIATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK AtL SEWER LINES DISPOSAL FLD. PROP. LINE E FOUNDATION I AGRICULTURE WELL # OTHER WELL PITS/SUMPS ;INTENDED USE TYPE OF WELL 4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS _❑ Industrial ID Open Bottom El Manteca Dia. of Well ExFavation Dia. of Well Casing -ter ' �"_Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 3 ❑ Public , ❑ OtherLlDelta Depth'of Grout-Seal S Type.,of Grout Cj `C7 Irrigation - A ox.i_Depth �❑ Eastern `•,i Surface Seal installed by Repair Work Done ❑ Type of Pump H.P.4 -State Work-Done Well Destruction ❑ Well Diameter Sealing Material itop 501 j f i I Depth`. ' i Filler Material iBelow 50'1 'TYPE OF SEPTIC WORK: NEW INSTALLATION XL—REPAIR/ADDITION ❑ DESTRUCTION ❑ (No.septic system permitted if public sewer is $ f °^ :` available within 200 feet.) I t Installation will serve: Residence_ Commercial_`0 her 7 Number of living units: Number of bedrooms 1 t Character of soil to a depth of 3 feet: ' -Water table depth SEPTIC TANK a7 M.,fype/Mf d Capacity 3 No. Compartments PKG: TREATMENT PLT. Q 1 j `_ " �' Method of Disposal Distance to nearest: Well Foundation 3 Property Line { LEACHING LINE J moo. & Length of lines (rn ` / �� - Total-length/size FILTER BED 1 ❑ Distance to nearest: Well/ '� FoundationF_¢ Property Line SEEPAGE PITS 1,-Mepth Size .3G, Number' ' 62A SUMPS ❑ Distance to nearest: Well 't Foundation Property Line DISPOSAL PONDS ❑ hereby certify thai,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 HealthDistrict. 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 person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature t. certifies%t% ollowing: "I c 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 ifornia." " The applicant t all for all aqui dins ions o p to drawing reverse side. Sign Title: -Date, r FOR DEPARTMENT USE ONLY 9j Application Accepted by Date 1 Area + 1 Pit or Grout Inspection by Date Final Inspection by Dater Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354638.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE t INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"NO. + EH 1344(riEV. 16!83} EH 1428