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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone {209} 456-6781 R E G Eq�y�g PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) AUG ' 1 q V. 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 welllpuf"�6 flyV1vM1p and Regulations of the San Joaquin ti Local Health District. AL HEALTH I HVAITISEpIncES Job Address 3 Si AL JiA) City &"Lot Size PM ; Owner's Name LEO G f_)A)z ti L� Address �___�.� Phone gip,; Contractor_ rf �,31f 16fFF�L { �` Address , %i License No / Phone6W2_2,0,7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,Domestic/Private LJ Gravel Pack- - ❑ Tracy Type of Casing t Specifications M Public Ll Other ' ❑ Delta Depth of Grout Seal Type of Grout--- 11 rout11 Irrigation --Approx. Depth I Eastern Surface Seal lnstalled-by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 &&,110 4/&LIL Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR1ADDiTION l,.i . DESTRUCTION I I (No septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence= Commercial- Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EDType/Mfg Capacity No. Compartments } PKG, TREATMENT PLT. ❑, F. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size` 3 ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑l� i + `1 Thereby 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" y Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this peimit 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- lion laws of California." '---- The applican u1 t call for all re red ins ctions. Complete drawing on reverse side. Signed X is Title: ��l. ... Date: DEPARTMENT USE ONLY, �y �{ Application Accepted by Date I }j Area lv Pit or Grout Inspection by Date Final Inspection by Date��l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 17 Manteca a23-7104 CI Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT DUE AMOUNT REMITTED CK HRECEIVED BY DATE [PERMIT NO. + EH13-24{REV-i i H 51 731 ](�� EH 1428 �( V r 1