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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '("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 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 n ,^ Job Address F�e• 10 City LSCO101) Lot Size PM ++ r Owner's Name _ G i� S( t(�1 aq Address G Phone F e� Contractors f` Address O License No. ��' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (1 — Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by r X ` Repair Work Done ❑ Type of Pump H.P.`! State Work Done_ "U Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Y Commercial_ Other Number of living units: �_ Number of bedroomsIN Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Q, Type/Mfg _._. d—L Capacity__J_'a__� No, Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well - 100'_ FFoundation io Property Line. LEACHING LINE ler No. rat Length of lines — Total length/sizr FILTER BED ElDistance to nearest: Well Foundation Properh}r Line SEEPAGE PITS I I Depth Size Number SUMPS LZ Distance'.to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health Di§trict. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all recLljire_dJnspections. Complete drawing on reverse side. X Signed. Title: t.d - Data: �7 OR D y RT _ ..ONLY Application Accepted by Date Ar Pit or Grout Inspection by Date Final Inspection Date Additional Comments: E! 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 CK RECEIVED BY ATE PERMIT'NO. +.Eli 13-21(REY. /t+5) d9 Eli 11.26