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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 11 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address v k City Lot Size PM I� ti a"? f �� L3 Owner's Name .. Address Phone 0 Contractor ddress I120_ fJ License No. s�? �Phon�/ v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ "PUMP INSTALLATION ❑ YSTEM AIR ❑ OTHER -❑ ^� DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION yt`. 1AGRICU.LTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAj„CO STRUCTION SPECIFICATIONS ❑ Industrial C1 Open Bottom ❑ Manteca a of-Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty a of Casing Specifications I"1 Public ❑ Other ❑ Delta D pth of Grout Seal Type of Grout I I Irrigation —Approx...Depth—l-1_Eastern-.. S rface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Wo„k Done _ Well Destruction ❑ i Well Diameter Sealing Material (top 501 Q Depth Filler Material (Below 50') — O TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) , Installation will serve: Residence Gommercial Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: i Water table depth 10 SEPTIC TANK p❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT'. ❑ Methodof Di os _ Distance to nearest: Well� Foundation Property Line %L LEACHING LINE ❑ No. & Length of lines ` 1A Total length/size FILTER BED CI Distance to nearest: Well _ Foundation_ Property Line I SEEPAGE PITS l I Depth Z Sire Number f SUMPS ❑ Distance to nearest: Well�� Foundation .�U• Property Line DISPOSAL PONDS El 11 t 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicantst call for all quired in ctions. Complete drawing on reverse side. �f Signed X � Title: Date: 12-^1 Ltd .. IM + DEPARTMENT USE ONLY } Application Accepted by QAQ C—"V Date 1�� C Area I r. lZ(i.rl (�)itional Grout Inspection by Date -YLI Z t(V`i Final Inspection by Date I� Comments- IIt ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., Cj9001 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE INFO CASH+.EH 13-241REV.I K5l EH 14'26 i �i