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} APPLICATION FOR PERMIT Q SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) J l,N R"gul� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei }1W�Wf1 1- - made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and j@1) �cjWn Local Health District. F Job Address R City Lot Size P M Owner's Name lzvi Address 20 w , Phone ^' 7 ° ContractorAddress =�- "I License N,.2j-?4ql PhoneZa 77 TYPE OF WELL/PUMP:- NEW WELL ❑ �W-EEL-LL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATION ❑ 1 SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER NESISP( AL FLD. PROP. LINE LI_ FOUNDATIONS K AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private —❑ Grave! Pack ❑ Tracy Type of Casing Specifications i"1 Public ❑ Other n Delta Depth of Grout Seal I Type of Grout �Q Irrigation _Approx. Depth [ Eastern Surf ce Seal Installed by Repair Work Done ,t4' Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth TFiller Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRIADDITION i I DESTRUCTION I I I (No septic system permitted if public sewer is Installation will serve: Residence Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ter table depth SEPTIC TANK ❑ Type/Mfg Capacity Water PKG. TREATMENT PLT, LJ1 Method of Disposal Distance to nearest: Well Foundation Property Line 1. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f N SEEPAGE PITS I i Depth I Size { --o- - • -- _ Number SUMPS ❑ Distance to nearest: Well Foundation _ Property Line � �' 'y DISPOSAL PONDS ❑ } 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 applicant m t tail r all re red inspections. Complete drawing on reverse ide. Signed X Title: Date:fJr 30 2 V. — /�l elFO DEPARTMENT USE ONLY Application Accepted by (&"c-6 Data Arae Pit or Grout inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6791 ❑ 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 I FEE AMOUNT DUE AMOUNT REMITTED INFO ' ASH RECEIVED BY DATE PERMIT'NO. + EH13-241REV.IIK5)