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' - 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete, in Triplicate) r `Application is hereby made to the San Joaquin Local Health District fpr 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. , Job Address y City CA Lot Size PM Owner's Name OL Moo" Address '07 A) Phone Contractor's Name, LiGense.'No. Phone 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION � AGRICULT.URE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA'; CONSTRUCTION SPECIFICATIONS ❑ Industrial d Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications ❑ Public ❑ Othert, © Delta Depth of Grout Seal, Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastenr Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth _-,Filler.,Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet:) Installation will serve: Residence�'Commercial -Other 1 Number of living units: { Number of bed roo' s r ; Character of soil to a depth of 3 feet: Water table depthopo SEPTIC TANK l- Type/Mfg G),L (A#Xapacity---L No. Compartments Z PKG, TREATMENT PLT. ❑ D r ! / ` �1 Method of Disposal ro erty Line O Distance to nearest: Well FoundatioFl d 1 p ��I ,g LEACHING LINE ❑ No. & Length of lines G r Total length/size 26 # FILTER BED C3Distance to nearest: Well-&O&O Foundation / 01 _ Property Line SEEPAGE PITS Ra'-Depth 2 F f Size Number- 3 % IV SUMPS ElDistance to nearest: Well 0 0 Foundation t Property Line a 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. 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." A The applicant must call or quired inspections. Complete drawing on.((raverse side. " Q Signed Title: (`J WA)'AL_ Date: FOR DEPART ONLY U5ONLY Application Accepted by v Date 7— 2 .�^ Area Pit or Grout Inspection by Date Final Inspection by /y Date Additional Comments: e C � 5_�aoz_ r7 - ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT"NO. INFO CASH l_EH 13-24(REV.10183) `�'� �l 1 ( EH.14-284ti f �. �� .. -