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;�.� 4PPLICATION FOR PERMIT a r. v SAN .lOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZELTON.AVE., STOCKTON, CA Telephone (209) 466-6781.. PERMIT EXPIRES-11 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 DistrictR Job Address fJO�T �/ �� t`n 107t" I'fQy[- CityLot Size z PM Owner's Name LAN. Address V,3 ULY Ma r A-A.r PhoneO Contractor�A 'ph Addres 3�� L`!1V0--, License No._�Phone Z� j TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ OTHF9 LJ DISTANCE TO NEAREST: SEPTIC TANK Od SEWER LINES DISPOSAL FLD./U� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT10146 04 fl ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing ',Domestic/Private -Gravel Pack .Tracy Type of Casi Specifications mog 14't ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 4W Type of Grout IX ❑ 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 5(Y) ' t Depth Filler Material(Below 50') �— TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑� Distance to neaiest:"r -well Foundation _~~' Property Ghi6 7 -- ' 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 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." The applicant m all for all r red inspections. Complete drawing an rside. /lP� Date: Signed Title: '(�• FOR DEPARTMENT USE ONLY Application Accepted by Date y Area I •, Pit or Grout Inspection by Qateod� r F , -< Final Inspection by Date Additional Comments: t' ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy ^$ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. L . EH 14-x8(REV.1/0 —7 p . EH 14-26