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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA —/ Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} Ao 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. 175 City Lot Size. A�rPM Job Address Owner's Name,-T , 1✓2.4s Address Phone Contractor's Name_LECre ��p+c�-t-- License No. Phone S 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 C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications N El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation . -__,Approx. Depth ❑ Eastern Surface Seal Installed-by -J Repair Work Done ❑ Type-off Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 . ,. Depth f 'Filler Material (Below 501 TYPE OF SEPTIC WORK: -NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re idence��Commercial_ ther { Number of living units: �� Number of bedrooms Character of soil to a depth of 3 feet:_ nh +�J - - Water table depth SEPTIC TANK &lJlype/Mfg C C e tF Capacity y!�¢ No. Compartments PKkd. TREATMENT PLT. ❑ / Method o ' posal Distance to nearest: Vel! Foundation / Property Line tQ WWI 111A I LEACHING,LINE 'P- No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well I Foundation Property Line SEEPAGE PITS l",pth �Sizei , yNumber SUMPS C1 Distance to nearest: Well Foundation� Property Line DISPOSAL PONDS ❑ 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 I 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 cert' 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 California." The appiic t u�all �allu�irensp�en Complete drawing on em" Signe Title: ' Date:,5 -)3 T t,, FOR DEPARTMENT USE ONLY l Application Accepted by Date r Area Pit or Grout Inspection by Date Final Inspection y Date Additional Comments: Mo I �^ '�1 � W 4Stk 4866761 ❑ Lodi 369-3621 1,Plf 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 9520 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. INFO CASH + EH 1324(REV.10183) ftD W 5 Z§lefo f EH 14-26