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APPLICATION FOR PERMIT 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) 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 i 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.qq � L s PATTE�S[3A1 - All—,- City '57/KC� Loz t Sie 3��-A� PM JobAddress. Owner's Name= Address Phone s Contractor L-e V 0 wo co_1b +Address foe C Al _ L L-`AA1 At/, License No.41- Y7L Phone q& "397/ZZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ € SYSTEM REPAIR ElOTHER ❑ I 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 r ❑ Industrial ❑Open..Bott#fn ❑.Manteca i Dia. of Well Excavation Dia. of Well Casing !l El Domestic/Private ❑'Gravel Pack ❑Tracy € Type of Casing Specifications ❑ Public ❑Other , f ❑ Delta Depth of Grout Seal Type of Grout a ❑ Irrigation �p►irbx.:Depth " Ell—Eastern Surface Seal Installed by Repair Work Done ❑ Type- -of Pump; ' 0i• H.P- State Work;Done"' �'"`' Well Destruction ElWeil Diameter^ ' Sealing Material Itop 50'1 t ._a__. t Filler Material Melo 50'1 1 TYPE OF SEPTIC WORK: NEW INSTALL:ATIQW17 REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will servel-Residence � Commercial! Other � f Number of living urnts: _J— Number of bedrooms Character"of soil to a depth of 3 feet: I e-L,q y Water table depth SEPTIC TANK IthType/Mfg I A e P9f'�- _ Capacity)Zoy :No. Compartments -PKG. TREATMENT PLT. ❑ t i £Methodao D sal Distance to nearest: Well ►L_D` Foundation 10 Property Line s., so LEACHING LINE ❑Y No. & Length of lines G'v t c I-/Al(s Total length/size FILTER BED ❑ Distance;`to'nearest: Well Foundation Property Line:r SEEPAGE PITS ❑ Depth. r'_.SSizo= Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i k DISPOSAL PONDS ❑ i i ! .1 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 must call for all required inspectio s. Complete drawing on reverse side. Signed X Title: ' Date: l8 A - Y FOR DEPARTMENT USE ONLY �y Application Accepted by Date e '�1� rea Q Ik Pit or Grout Inspection by , Date - Final Inspecti by 1 , Date ji Additional Comments: 1 ❑ 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 95201 FEE AMOUNT DUE , AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH �j 1 + EH 13-244REV.1/8 57 �Q. UU ^��5'� �1��•� EH 14-29 +