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:Y V" .►' .... r ' APPLICATION FOR PERMIT '' SAN JOA¢UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �til•cwt Telephone {209} 466-6781 (�,p 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'Sad Joaquin County Ordinance No.549 for sewage or No. IBM for well/pump and the Rules and Regulations of the San Joaquin Local Health District.,, Job Address �-�. City Lot Size PM -. A „,/}� - �.� Owner's Name' — 1, Address LC"._ - Y Phone / s Contractork /a rU,,S f Address �� `�' �� 'Li se Nd --L� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C:-_. 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 -wDia of-Well-Excavation--.+os Dia. of Well Casing ❑ Domestic/Private ❑ G�favel Pack ❑ Tracy Type of Casing Specifications ❑ Public y❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation fi Appra Depth ❑ Eastern Surface Seal Installed by F. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wei l*Diamete :!� Sealing Material (top 501 . Dept h J '*`14 Filler Material (Below 501 b I. TYPE OF SEPTIC WORK: NEW INSTALLATION 01i REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) InstallationFwill serve: Reside nce_-I Commercial.,,,,Other, ---F Number ofliving units: 4 Number of bedrooms Character of soil to aapt of 3 feet:' Water table depth I SEPTIC TANK aa Type/Mfgi Capacity No. Compartments PKG. TREATMENT PLT- Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE LINo. & Length of�lines Total lengthf,'size FILTER BEDS ❑ Distance to nearest: Well Foundation P.roperxy Line SEEPAGE PITS ❑ Depth Size Number _ - DISPOSAL PONDS E,SUMPS ❑ Distance to nearest: Well Foundation Property Line 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" come subject to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature certifies the following:"I certify#hat in th'e$6rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif o nia" h{ The applicant t ca.11 for all requi spec ns. Complete drawing on reverse side. p I t _s l� ¢ Signed Title: Date: FOR DEPARTMENT USE ONLY �'eT• � Lam. � "' � - Appli on Accepted by r f Date — Area Pit or Grout Inspectio Date Final Inspection b Dated i MIA ?, Additional Comments: ❑ Stk 486-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835- KSS Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE I AMOUNT REMITTED CA N RECEIVED 8Y DATE PERMIT"NO. INFO + EH 13-24{REV.tie s} � LZS `/ o /"blZ3 EH 14-28 I