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f- APPLICATION FOR PERMIT 4 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 Ryles and Regulations of the San Joaquin Local Health District. 1 p � Job Address �/ �% .l v!/ T !Ind �i�1 _ City�jeIPQV Lot Size =r PM Owner's Name LGAAT4 .C�z1, Address Phone 1 Contractor : wUGf Address f', 4< / ! � ! _License No. Phone ` �� TYPE OF WELL/;PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ c� 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 ; ❑ Public _ ._._- pAther —L'- Delta Depth-of Graut.Se#I. _ _ _ ,Type of Grout Tut ❑ Irrigatioh __-..._Approx.!Depth ❑ Eastern Surface Seal Installed by .....uW ( _ Repair W oJrk Done ❑ Type of Pump H.P. __' State Work Done Well Destruction El Well Diameter Sealing Material (top 50') 6 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 j available within 200 feet.) Installation will serve: Residence Commercial_ Other lt Number f living units: J�-_—Nurnber of bedrooms-- k Character of soil to a depth of 3 feet: Water table depth /0 SEPTIC TANK Type/Mfg Capacity tall""/—No. Compartments i PKG. TREATMENT PLT. ❑ U�" e 33 � �-- Method of Disposal r Distance to nearest: Well � Foundation Z4 Property Line � LEACHING LINE 5V No. & Length of lines, ,r�— �O-�_T- - -- -.-..Total-lengthhsize FILTER BED ❑ Distance'to nearest Well 105 Foundation OLTr Property Line G SEEPAGE PITS ❑ Depth 'a. 'Size Number SUMPS _❑ Distance to nearest: r -Well foundation Property Line DISPOSAL PONDS ❑ Ihereby certify that I have prepared this'appiication and that the work Will be done in accordance with S'an Joaquin county ordinances, state laws,:and n rsules and regulations of,the San:Joaquin-Local'Healf `District. Home owner or licensed agiin'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`D.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,•,Ia`hall employ persons subject to workman's compensa- tion laws of California." The applicant must tali for requ" d inspections. Complete-drawing onwreve'rse side. i �� qtr .•�+- ��F Signed X' �j � .,�G`✓ y, _ Title: « _ Date: 214 FOR OEPARTMENT USE ONLY -� Application Accepted by ` '" Date '� � � Area Pit or Grout Inspectio y Date-- =Fina! Inspection by- bate Additional Comments: ❑ 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 r i � � I INFO AMOUNT DUE AMOUNT REMITTED CASA . :_ RECEIVED BY a DATE PERMIT`N0. +'EH13-24(REV.1/115) i EH 14-26