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R �C e� ' v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON 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.t.-Ty L�' Job Address V / r )E. woo��J/�oo V, A Z� �Y�C Ci o e� Lot Size P'G PM Cro Owner's Nam LU'Uod/ e�A Address Phone Contractor's Name ` License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ rn 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 IJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications � ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern 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 pu is sewer is available within 200 feet.) ' rnr Installation will serve: Residence_ Commercial_ Other r�PM �' r J Number of living units:_L Number of bedrooms�_ maflrr �16 f 1 r"4 k" Character of soil to a depth of 3 feet: K r P Water table depin SEPTIC TANKType/Mfg CLQ Ca aci .O� p ty_r Na. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ,10,e1 Distance to nearest: Well Foundation Property Line LEACHING LINE Z?'No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 211' Foundation_7?1 d I Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 sugh manner as to become subject to workman's compensation laws of California._"Contractors hiring or sub-contracting signature certifies the following:" 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 Calif nis The applicant m all f ed in tion _drawing on re rse side. Signed ` Title: Date: F PARTMENT USE ONLY Application Accepted by Date /yy p Area Pit or Grout Inspection by - Date incl Inspection by O pate co Additional Comments: [f, S ��- G . , f -r f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 823-7104 ❑ Tracy 83 641 1� ]__ f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 I �. "rd cwt: FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT`NO. INFO 1J CASH + EH 13.26(REV,10!831 „[J S- L +" _ CA— }--1 �`-Lj a EH 1426 1 !9 {� 1