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.f APPLICATION FOR PERMIT I SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t {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.. I Job Address ~ City Lot Size PM Owner's Name :' t" Address Phone `. Contractor. -J LL- Address 50 Lk c License No. avd Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑' — SYSTEM REPAIR ❑ OTHER ❑ 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 F1 Other a ❑ Delta. Depth of Grout Seal Type of Grout—-. I I Irrigation __.-Approxi Depth "I 'l Eastem , Surface Seal Installed by - Q Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction. ❑ Well DiameterSealing Material (top 501 -- Depth r F' Material- (-Below-501--/TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIWADDITION E I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) F Installation will serve: Residence L Commercial_Other { r Number of living units: Number of bedrooms G Character of soil to a depth of 3 feet: .` Water table depth + SEPTIC TANK 1�Type/Mfg f– Capacity 4` No. Compartments It PKG. TREATMENT PLT. ❑ g Method of Disposal tf : Distance to nearest: Well Founda ion ..,_ Property.Line_.1�1.�� L; LEACHING LINE & Length of lines f � Total length/size FILTER SED LI Distance to nearest:- ,-Well Foundation Property Line C:) SEEPAGE PITS I I Depth Size Nu mPor --� SUMPS stance to nearest: Well Foundation_ Property Line �� DISPOSAL PONDS ❑ I hereby certify that 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 Health District. ---- 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 lay any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certify he following: "I 76 ' that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensation laws o 1iIarnia.The applica t mus II e .in cti Co I2t.drwing on reverse side.Sined t–� itle: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r� Area �...� — Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-301 Ef Manteca -7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, k., A 0 "J ✓ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO _ -�: CASH `7 �(Ja --71 . a.EH"13-24tHEV.i/n5y EH 14-26