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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address f 3S$a �r .City! -e rt f Lot Size a PM Q, Owner's Name `' `L�1eM'!, It �119 L',d Lei Address ; �F`` � c Phone d�v16 Contract � i tl Address f �( _ 6GCf License Nod r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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-""""'rCT-Gravel-Pack" ' '❑ Tracy -"- - " -Type ofCasingSpecifications� S ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H:P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material,(Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPA( /ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is I 'available within 200 feet.) s Installation will serve: Residence= Commercial Other Number of living units:—4— Number of a rooms / Character of soil to a depth of 3 feet: Water table depthd t SEPTIC TANK ❑ Type/Mfg a Capacity " TNo. Compartments PKC. 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 2—'Depth Size Number ; SUMPS ❑ Distance to nearest::r --,-Well Foundation Property Line Ono DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will 6e 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 t employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i certifies the following:"I certify that in the performance of the work for whfch this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mut call for all- quir inspectio s. Complete drawing on reverse side. Signed Title: V::'F Date: FOR PARTMENT USE ONLY Application Accepted by Date �5 Area PR r Grout Inspection b� ate �� Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'. 0. + EH 13-241REVI /O EH 1428 -70 � �1 V