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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 wotk;NefeiV described. This application is 1 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules aid Regulations of the San Joaquin Local Health District. ` Job Address W �� City PM / IIJ o Owner's Name 5LJ &Y,� Address A" ,.� Address ' 0 License No. L12 ContractorAll AiiiC TYPE OF WELL/PUMP: NM WELL X t ref WELL REPLACEMENT ❑ DESTRUCTION LJS PUMP INSTALLATIO ❑ Well SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK AIM SEWER LINES 106�ll � - DISPOSAL FLD..�P/,A� PROP. LINE 1 u FOUNDATION AGRICULTURE WELL A��lli` OTHER WELL__3 _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f( ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack` ❑ Tracy Type of Casing Specifications M Public 'K Other�& CI Delta Depth of Grout Seal b Type of Grout I I Irrigation W..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is p, 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 M SEPTIC TANK LI 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 I I Depth Size Number SUMPS ❑ 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 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 SComments:;;R all for all re uir d inspections. Complete drawing on reverse side. i SignTitle: Date: n —b R DEP TMENT USE ONLYiAppliby Date r Ara/Pit on by Date �O f Final InspectionDate Addi : 'i ❑ 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 FEE ' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATS PERMIT'NO. 1 S .. ,At�+,a-z.It,Ev.,,as, �3`�E�� -n-a �. � 3 a� EH 14-28 NAinl