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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone`f 2091 466-6781 PERMIT EXPIRES'? YEAR FROM DATE ISSUED (Complete'jn 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 Sari Joaquin Local Health District. Job Address I q E. G L VC Cy Ci -0 1e/�! Lot . •� „ Size pM. e e VX _�� ISN1� ii1 G7 Owner's Name ' ` 44ddress -`T f R E' E b/ /U_/ y io r— Phone �a r r it Contractor J"��Y' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT-El- r DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ""DISPOSAL F PROP. LINE f FOUNDATION " AGRICULTURE WELL WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL ' PROBLEM AREA CONS ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca la. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Ll Type of Casin J' r 9 Specifications ❑ Public ❑ Other elta Depth of Grout Seal 'r Type of Grout ❑ Irrigation ° Approx. ❑ Eastern Surface Seal Installed by + Repair Work Done ❑ Type mp Y H.P. State Work Done_ Well Destruction Q' I Diameter -Sealing Material fto'p!0b Depth r Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ " DESTRUCTION (No septic system permitted if public sewer is } available within 200 feet.] Installation will serve:i Residence v Commercial Other (' Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depths � SEPTIC TANK Q Type/Mfg Capacity No. Compartment's, ± PKG. TREATMENT PLT. ❑ y "� , Method of Dispo al i Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines + Total length/size t j FILTER BED ❑, Distance to nearest: Well Foundation Property Line -------------- SEEPAGE PITS 1❑ Depth Size Number + , SUMPS' Q ..Distance,to nearest: Well Foundation I 'Property Line'" , DISPOSAL PONDS ❑� M 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.", 1 The applicant must all or all required.inspectionls. Co plete drawing on revers side. Signed Title: N E Date: FOR DEPARTMENT USE ONLY Application Accepted by; f Date �� Area 03 Pit or Grout Inspection Date Final Inspection by Date" Additional Comments: Q Stk 466 6781 ❑ Lodi 3&9-73621 Mantes 823-7104 q Tracy 835-6385 0-)-) / f � Applicant Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, StCA°95201 r bj 2 S-e 7L'p FEE INFO AMOUNT DUE AMOUNT REMITTED CASH ° RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.t i fi 51 EH 14-29' � ,� }.