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II w - APPLICATION FOR PERMIT , : y' SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��lf �5i� xww ` (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 Cityzlz lot Size' PM °9 Owner's Name � Address �r 'r �`T 9.+x� - Phone dZ 4 �r Contractor 5ELee Address License No. 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 ;I FOUNDATION AGRICULTURE WELL OTHER WELL f is, - i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing �I 4 1 ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications' f'l Public Cl Other 1 Cl Delta Depth of Grout Seal Type of Grout I I Irrigation pprox. Depth 11 Eastern Surface Seal Installed by 4 Repair Work Done Type of Pump H.P. State Work Done i; Well Destruction ❑ Well Diameter Sealing Material Itop 50'I- R Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (] REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is i! favailable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of Iiving.units: Number of bedrooms p� Character of soil to a depth of 3 feet., w Water table depth i SEPTIC TANK ❑- Type/Mfg Capacity'-= No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance_to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number I SUMPS Cl 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 ff it call for all required inspections. Complete drawing on reverse side. Q !� Signed X ++�� Title: Date: i �FO EPA T USE ONLY. II Application Accepted by Date r� I Area Pit or Grout Inspection by Date -Final Inspection by Date Additional Comments: ❑ Stk .466-6781 ❑ Lodi 30-3621 ❑ Manteca 823-7104 U ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 INFO AMOUNT DUE t AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. k' r.EH 13-24/REV,tirs5l �L" ` t LcA U/ - 2,r)I I 4