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APPLICATION FOR PERMIT E '�{= SAN JOAQUIN LOCAL HEALTH DISTRICT 1* _,! O\A 1601 E:_HAZE TON�AVE., STOCKTON, CA Telephone (209) 466-6781 I ja o PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ 1 {Complete in Triplicate) a Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor �r�, cr q T s is made in compliance with San'Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule �Fi§ iil�t �ih� buin Local Health District. FERFJIITAERVICES Job Address 's! . UNION City h t Size PM Owner's Name 3F-, t `tom LCI 41s Address h 8 40k A 2 a L'��-/�TLY� Phone '7 Contractor Address M 17 License Nol 3 73 Phone 4t—TUNS TYPE OF WELL/PUMP: NE WELL E] WELL REPLACEMENT ❑– / DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR {6 OTHER 0 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 Ria- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other F] Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx.r Depth I I Eastern SurfaceiSeal Installed by �� f _ C Repair Work Done [Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Seating Material (top 50') Depth Filler Material (Below 501 —_ t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR)ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) lnstaliatio'Nwill serve: Residence_ Commer6 l Other Number of living units. Number of bedrooms ;;i- - r 'Charactel of soil to a depth of 3 feet: _ W,.,ater table depth - SEPTILTANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ j Method of Disposal Distance to nearest: Well Foundation Property Line i s• LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance'to neatest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL POND& ❑ I hereby certify that)bF .spared tl4is'applibfation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations the Joaquin LOG81 Health District. Home owner or lic sed agent' signature certifies the ollowin certi hat in the performance of the work for which this permit is issued, i shall not employ any pars in such ma e s to become sur t k n' mpensation laws of California." Contractor's hiring or sub-contracting signature certifies the foil Ing: "I certi at in th rf6' e r r ich this ii is issued,I shall employ persons subject to workman's compensa- tion laws of C//ifornia." ' { The applican hnus li r r ui om le fa a ng on rev s' e Signed X i Title: Date: 0 f FbR DEPARTMENT USE ONLY Application Accepted by ( f a. Date /mac Area Pit or Grout Inspection by Date Final Inspection by Date tt ! I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3M-1621 ❑ Manteca' 11823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental He"lti-h-P\eimit/!�e—ry 4ices 1601"E: Hazeiton•Ave- P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE tAMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ..EH 13-24 1 REV.IJAW � r EH 14.28 ell