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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) �D 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. ��f Job Address Wa�T, f -- __ City 51K Lot Size PM Owner's Names /D`�/ / L1 Address Phone Contractor e ®r ddress_�?/4 9.e��, License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION , SYSTEM REPAIR ❑ _., OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,,. -- .DISPOSAL FLD.r. PROP. LINE _L L FOUNDATION _---..J�_ AGRICULTURE WELL `"' OTHER WELL PITS/SUMPS AV INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /r ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ¢ Dia. of Well Casing domestic/Private AlrlGravel Pack ❑ Tracy Type of Casing 1G i` Specifications C1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout_ 7—AOV1 I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. State Work Done A, Well.Destruction ' Well Diameter Sealing Material (top ) Depth Filler Materiel,(Below 50'1a _ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I i (No septic sys em permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms `(:'1Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg Capacity No.�Compartments PKG. TREATMENT PLT, ❑ Method of Disposal r Distance to nearest: Well Foundation _ ''Property Line LEACHING LINE ❑ No. & Length of lines -otal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line R SEEPAGE PITS I ) Depth Size Number SUMPS ❑ Distance to nearest: 'Well Foundation I Prhperty 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 Di$trict. Rome 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 requir s. Complete drawing on rev rse side. +� Signed X• Title:, Date: FOR REPARTMENT USE /NLY Applicatiori Accepted by aL pate ` Area I r Pit or Grout Inspection by Date d Final Inspection by Date 10 Additional Comments: C Com B5- r `J r q S f`t�i ❑ Stk 466-6781 ❑ Lodi 516-36210 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Enviro menial Health Permit/Services 111601 E. Hazelton A P.O. Box 2009, Sik., CA 95201 l�6buckC� w 't�►.1Uj,eolpf—O C 11 c,`lv.- 1, ,_t INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM�IYyNO. a EH13-241REV,iin5r //� c o EH 14-28 (J (�(f / y