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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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/of 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 &2r Q City Lot Size PM Owner's Name LyCle4* � Address g Phone C' Contractor # Address�aT l[x' 5t:;132(/License NoPhone e"lf TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION - SYSTEM-REPAIRT❑ --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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pac'k ❑ Tracy —` Type of Casing Specifications I'1 Public ❑ Other 171Delta Depth of Grout Sea] Type of Grout I I Irrigation _..Approx,rDepth I i Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump_�, H.P, State Work Done Well Destruction ❑ N Well Diameter Sealing Material (top 50') Depth �1~� Filler Material f Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) - ''� Installation will serve: Residence Commercial_ Other T 6 Number of living units: Number of bedrooms 1j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg) Capacity No. Comparfinenis, PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Iv1 r'I v v v FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth _ _Size _ _ _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 cf-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 applicanLipVst call fortal required inspections. Complete drawing an reverse side. k — ► .� Signed TitleA"— R DEPARTMENT USE ONLY f� `1h, f �! �` Application Accepted by [ F _ Date .i / Area Pit or Grout Inspection by { Date Final Inspection by /�'��` Date 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. Hazelton Ave. P.O. Box 2009 Stk. CA 95201000000 FEE INFO AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT NO. +.EH 13-241REV. ii„s1 1 ER 14-28 �/ A 41 o