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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Job Address 2 0 City Lot Size PM Owner's Name_c , -_a,"_ Address— Phone Contractor Address7-14? License No'-.41-179Y Phonef' v _02 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTUVE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AEA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing * Specifications * Public 171 Other 1=1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump fi. — tate Work,Done _ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIF,ADDITION l I ES Ryl IO l 1 1 N septic system permitted if public sewer is /I/P.f.!— L��aifahle within 200 feet.) Installation will serve: Residence commercial— Other � -�fr� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 0 Water table depth SEPTIC TANK ❑ 'Type/Mfg 'Q Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal uu Distance to nearest: Well _/0_ Foundation Property Line t`0 d LEACHING LINE ❑ No. & Length of lines To I length/size FILTER BED ❑ Distance to nearest: Well ` Foundation Property Line SEEPAGE PITS 11 Depth Size wNumber SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 ust coil fo equired )nspections. Complete drawing on reverse side. r Signed X Title: GL.r+�" _ ...,. Date: _Z ` G— FOR DEPARTMENT USE ONLY 1 Application Accepted b Date G Area—LII—.. Pit or Grout Inspection by Date Final Inspection by ,"-- Date 12 FA Additional Comments: f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/x51 ;6),/ {j J'7D EH 1428 O ✓PC