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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH.DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA /—,�i-3 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, k. ,Job Address City Lot Size PM Uru f Owner's Name _ _�� ALJ V Address 3 Phone Contractor Address-1-3 bl License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA T.- SEPTIC TANK SEWER LINES DISP PROP. LINE FOUND AGRICULTURE OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PR REA CTION SPECIFICATIONS ❑ Industrial ❑ Open Bat 171 Manteca Dia. of Well Exxca Dia. of Well Casing ❑ Domestic/Private ❑ el Pack ❑ Tracy Type of CasiSpecifications 11 Public F] Other ❑ Delta Depth of Grout Seal a of Grout I I irrigation __.Approx. Depth I I Eastern Surface Sea[ Installed by Repair Work ne ❑ Type of Pump H.P. State Work Done_ b Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 _ ^ TYPE OF SEPTIC WORK: NEW;INSTALLATION I1 REPAIR/ADDITION l l DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_' Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ „, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size rc' Number SUMPS L-] Distance to nearest: Well ` Foundation Property Line DISPOSAL PONDS ❑ w 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 applicant mutt call for all re uired inspections. Complete drawing on reverse side. r I Signed X_ Title: iJ�"y�(V Date: FOR,-DEPARTMENT USE ONLY F ` ~1 I r !� Application Accepted by Date Area Pit or Grout Ins � pection by Date F'71 ;peron'by_ Date Additional Comments: 17 Stk 466-6781 ❑ Lodi -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., C,65201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT'NO. +.EH1324 1REV.t i N 51 EH 14-26 - i