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ri APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTS 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 !PERMIT EXPIRES llYEAR FROM DATE ISSUED JUN 19$9 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the 1&4 44E Y&MNA,§Wlication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules San Joaquin Local Health District. t Job Address 141 LJ L/1 r " City Lot Size PM t_ Owner's Name Phone Phone Contractor Address I`� d �tiz License No.z¢-53 � _Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKt SEWER LINES DISPOSAL FLD. PROP. LINE =;- -FOUNDATION-c - ------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 `�omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other ❑ Delta`y Depth of Grout Seal Type of Grout I I Irrigation - rox. Depth__..1.1 Eastern Surface Seal Installed by Repair Work Done ly, Type of Pump .P H . State Work Done E Wm Well Destruction ell Diaeter 4 Sealing Material (top 50'1 Depth ' Filler Material (Below 501 -- J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is "l available within 200 feet.) O 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1,PKG. TREATMENT PLT. ❑ Method of Disposal ,. w Distance to nearest Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance toinearest: Well Foundation "' Property Line SEEPAGE PITS 11 Depth `I 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-sig nature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner`as_to become subject to workman's compensation laws of California." Contractor's(tiring or sub-contracting signature certifies the following: "I certify that in-the performance of the work for which this permit is issued, (,shall employ persons subject to workman's compensa- tion laws of California." The applicant f for all required-inspections. Complete drawing on reverse side. Signed X Title: Date: o'` FOR DEPARTMENT USE ONLY } Application Accepted b Date 4 Area !!! Pit or Grout Inspection b Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 AQplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. INFO CASH +.EH 13-24(REV.i/)15) EH tt-2e � 1 J