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APPLICATION FOR PERMIT 'u 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'Rules and,Regulations of the San Joaquin Local Health District. a Job Address U4r d Lam- 1 City �Lov ize. PM Owner's Name 0, h ?,`I — Address 1� l— ..PCO. Phone... I Contractor's Name ' License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ # SYSTEM REPAIR HE R.❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD °T� .PROP LINI T FOUNDATION AGRICULTURE WELL OTHER,WELL PI%/BUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial 1171 Open Bottom ❑ Manteca Dia, of Well Excavation 1. Dia: of WeII:CaSing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifiuetions-; ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of GrvutM ;t t El Irrigation L—Approx. Depth q Eastern Surface Seal Installed by Repair Work Dane `Type of Pump fbt H.P. _ State Work Done, Well Destruction ❑ Well Diameter Sealing Material (top4l)')'� Depth `sem. Filler Material (Below 50') ; a TYPE OF SEPTIC WORK: AEW,INSTALLATION ❑` REPAIR/ADDITION ❑ DESTRUCTION ❑iI o septic system permitted 1f public sewer Is available within 200 fegt.l Installation will serve: Residence_ Commercial Other l Number of living units:I Number of bedrooms Character of soil to a depth of.3 feet: — Water table depth C) SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. El `, �- _ Method of Disposal Distance•to nearest: _. Well Foundation Property Line •JCj LEACHING LINE ❑ No. & Length of lines T `"' Total length/size. FILTER SED LJ Distance to nearest: , Weil Foundation Property.Line SEEPAGE PITS n Depth �* 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:; , Nome owner or licensed agents signature certifies the following: 'f 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." Contractors 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 applic st II for all rred ' pect ns. Complete drawing on reverse side. Signed Title: r P 5. Date- s FOR DEPARTMENT USE ONLY Application Accepted b PP p Y� Date � 'Area • • Pit or Grout Inspect( y Date Final Inspection by bated rZ ' Additional Comments: ❑ Stic 466-6781 ❑ Lodi .3693621 ❑ Manteca 923-7104 ❑ Tracy i a 4- i + Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;Stk., CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"iVO. INFO CASH +EH 13-241REV.101$31 EH 14-28 S n. - �� •�'�G, :' '9 tG..y1�?1