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APPLICATION FOR PERMIT IZ1 ',4, r..., , -„,_•, ' SAN JOAQUIN LOCAL HEALTH DISTRICTh—k--. u .,� ° 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 13 PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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. �J j Job Address,/ – City C".*_/Lot Size PM Owner's Name L!d if kIA ___ Address Phone _Contractor Utl�c] 1– Address_11 License N0.n?6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i_DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA-T10NS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J Domestic/Private Cl Gravel Pack LJTracy Type of Casing Specifications .� 1'I Public F1 Other ll Delta Depth of Grout Seal Type of Grout _. I I Irrigation _.Approx. Depth l I Eastern fZ urface Seal Installed by Repair Work Done ❑ Type of Pump �r H.P. State Work Done Well Destruction O Well Diameter L�t Sealing Material (top 50') Depth._, ln.�y Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I INo 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 I No. Compartments PKG. TREATMENT PLT. C1 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 l I Depth Size Number SUMPS Ll Distance 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-Di§trict:– t 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 certifiesthe fo! g: "1 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 Eifo ia. The app nt st call for all fired ins tions.tComplete drawing on r rs 3 side. f Signed X Title: t,c� bate: -90 R bEPARTM T USE ONLY Application Accepted by Date ^/! Area 2 jr Pit or Grout Inspection by Date Final Inspection by '. . — Date Z v Additional Comments: �❑ Stk 466-6781 ; ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 -Applicant–Return all-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. I r EH 1 -24(REV.11 to 5) EH 144-26