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APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT-- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {2091 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f ; tiF �4"./ j {Complete in Triplicate} �r t -�-r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desdribed.This appl' tion 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 1 Local Health District. a •x• tG Al�� C/`Ya►sL"�1� �J�J F , City � rLot Size � 4� �1 Job Address Qll__ q s} n Owner's Name ah RI/ 0ddress LW40-03 Phone r J61 S�Zi Contractor's Name %q Ph License No. -- _ TYPE OF WELL/PUMP: r NEW WELLIKWELL REPLACEMENT ❑ DESTRUCTION ❑ �. 1 PUMP INSTALLATION ❑s � .kSYSTEM REPAIR CT � .-- .j�THER-� ' 'L 106 DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. �Q PROP. LINE .} T. �' _��.•„„,-FOUNDATION-"1^ AGRICULTURE WELL OTHER WELL PITS/SUMPS 56 r + r w z.. . INTENDED;USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S s f eq ❑ Industrial Open Bottom ❑ Manteca _Dia. of Well Excavation. Dia. of Well Casing C3 1Domestic/Private ❑ Gravel Pack ❑ TracyY� T Type of Casing ':Specifications 1Q �.• ❑ Public ❑ Other ❑ Delta g 4y-pe•of.,Grout ❑ 61 nsta Irrigation --Approx. Depth ❑ Eastern Surface Slled by; Y Repair Work Done p ye of Pump -H-'P. - — State-Wok Done Well Destruction Z/Well Diameter . . "` ' Sealing Material (top 50`)2-- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ - REPAIR/ADDITION ❑ DESTRUCTION-❑-1No septic system permitted if public sewer is '; ti -=Z-1 ,available within 200 feet.) � f Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms k ` 4 Character of soil to a depth of 3 feet: k V Water table depth SEPTIC TANK Type/Mfg C El No. Compartments PKG. TREATMENT PLT. 71 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." f The applicant t call for all uired ins ns. Complete drawing on reverse aid . Signed Title:,_!L, Date: 1 3 FOR DEPARTMENT USE ONLY Application Accepted by — Date Area Pit or Grout Inspection by -"f' Date f P Final Inspection by V Date �.. 1 Additional Comments: - ❑ Stk 4664781 ❑ 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.r CA 95MI FEE- AMOUNT-DUE`W UU-W EMITTED CASH � REC!IVED BY �OATE'T"�PERMIT'IVO, AM INFO + EH13-24(REV.10183) O + Q - v AV E11 1426 L 7 i