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APPLICATION FOR PERMIT :y 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. . Job Address /' O� 1 m y L i�N�i- -- City L"`+� Lot Size 0U , PM Owner's Name �e G I Address _ /L D r / wl_ Phone F 70 U Contractor L )4 L-icense No. Q !Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION OF PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ ! OTHER ❑ h K s di I ., 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �' Type of Grout 5 ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done '❑ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is L1___ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other - - Number of living units: Number of bedrooms .:-Character of soil to a depth of 3 feet: Water table depth SEPTIC,�T,ANK Z�7 ype/Mfq r Capacity No. Compartments , PKG. 'TREATMENT-PLT. ❑ � Method of Disposal Distance to nearest: g, Well Foundetio^n_ O Property Line'_ t I . . - - F LEACHING LINE 1L,.Rh. & Length of linesT Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS C!]_-Depth Size i � ! Numb r i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1� + hereby certify that I have prepared this application and Rhat the work will W done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District- p Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issuedr I shall not I oy any person-in such manner as to become subject.-to workman's compensation laws of California."Contractor's hiring or sub-contracting signature } certifie following:f'. ce.' that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's campensa_ -tion laws of ..ornia.' e applica must II for all r quir ins ns: v ple Ding on verse stfLJ VSisne Date: -- : FOR DEPARTMENT,USE ONLY Application Accepted by :Date Area Pit or Grout.Inspection by l' 0% --- --nate �" Final Inspection by 7 �!'a' ltla Date r y Q Additional Comments: )*ACV 4_144" s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MantacP823-7164 ❑ Tracy 83543$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S ., CA 95201 i FEE __ - -• ... INFON AMOUNT DUE- AMOUNT REMITTED CASHFRECEIVED BY DATE PERMIT'N0. i + EH 1374(REV.i/s 51 �10 EH 14-26 &J' - Tr b-•-tom