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I�. i APPLICATION FOR PERMIT ?' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ' — i (Complete in Triplicate) `fApplication 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. /Job Address / rP f �C/ V Q r City Lot Size PM Owner's NameIL)aJQ r _14A SGry a O Address y�G� lam@ D tr' r Phone i ContractorAddress License No. Phone :,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ li PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ kDISTANCE 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 I}❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �;❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications I M Public n Other n Delta Depth of Grout Seal " Type of Grout iLll I Irrigation ---Approx. Depth, l I Eastern Surface Seal}Installed by- Repair Work Done ❑ Type of Pump H.P. _State.Work Done F(I _ Well Destruction ❑ Well Diameter Sealing Material (top 501 l II Depth Filler Material (Below 501 t 1iTYPE OF SEPTIC WORK: NEW INSTALLATION ("I REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) ..Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of bedrooms 1 I Character of soil to a depth of 3 feet: Water table depth �\ }SEPTIC TANK ❑ Type/Mfg Capacity r No. Compartments \w PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest; Well Foundation Property Line i. r i LEACHING LINE ❑ No. & Length of lines t Total length/size j 1 BED L1Distance to nearest: Well ; Foundation Property Line ,IFILTIR :SEEPAGE PITS 1-1 Depth Size 1 Number ,SUMPS C] Distance to nearest: Well t Foundation r Property Line EDISPOSAL PONDS ❑ 1, i 0 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 II"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 i i:employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ircertifies 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 com ansa- istion laws of California." The applicant st call f r all req i eq i spections. Complete drawing on reverse side. ;Signed X Title: (9,11_fLa-,- Date: FOR DEPARTMENT USE ONLY �y 1 Application Accepted by .Date 7t Area q I l�Pit or Grout Inspection by / Date Final Inspection by Date O 1 Additional Comments: 1❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 623-7104 El Tracy 835-6385 !Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20119, Stk., CA 95201 E (FEEO AMOUNT DUE AMOUNT REMITTED n- HCK RECEIVED BY DATE PERMIT'NO. ' O i ♦ EH 13-2t(REV.l/k5)EH 11-28 L II