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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 456-6781 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address Lot Size 00 i PM I LA3 k �� J.' pp Owner's Name �,1� �, Address t� r��C ` Phone I Contrac - LU Address . 3� �1�� License fVo��ZZ(e- Phonla IDS TYPE OF`WELL/PUMP: j f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , 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 G D Industrial D:Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other. f__1 Delta Depth of Grout Seal Type of Grout__ I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - - - = State Work Done_ Well Destruction ❑ Well Diameter, Sealing Material (top 501 �--•- Filler Material (Below 50') TYRE, SFPTI ORK: FW INST_ALLATIO REPAY 1filADDITIO DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation-willserve:*-Resdce: Commercial t er_ Number of living units: Number bedrooms ` -�•. 5 r Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK T r ype/Mfg Capacity�.Q�..,___ �No:':Compartments PKG. TREATMENT PLT. c< ' f f Method of Disppsal' Distance to nearest. Well 50 Foundation � Property Liner LEACHING LINE No. & Length of lines Total length/size, FILTER BED ❑ Distance to nearest: Well Foundation��_ Property Line SEEPAGE PITS 11 Depth Size _2 _ Number r ADOSUMPS 'Distance to nearest: Well Foundation L� Property`Lin_e DISPOSAL PONDS X ` 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 applican st cal o all paired inspections. Complete drawing on reverse si Signed X Title: �,}4 Date: _ FOR DEPARTMENT USE ONLY (7 i Application Acceptedby�`� --�� ri Date Area ` Pit or Grout Inspection by Date Final Inspection bye-ice Date--��c7 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. Haielton Ave., P.O. Box 2009, Stk., CA 95201 e FEE INFO DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'NO. INFO (CASH + EH 1 .21(REV.I/a 51 7�1, ��/00 1•�S'tk 1� \ ' 1� • _I�- i t �� EH 1I4-26