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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6791 _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 . r(: 17` City CAS Lot Size. PM 71 Owner's Name L li O Lt Address _-20 42Z 7 ' Phone Contractor's Name, K License No. - ,?057Phone v -- 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well C9sing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing. Specifications i2 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 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION e DESTRUCTION Ll (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence /Commercial-_ Other Number of living units-—(— Number of bedroo s p Character of soil to a depth of 3 feet: _� >r �— Water table depth/C SEPTIC TANK ✓ Type/Mfg ��'>� LJ Ca C�i�/'_�Saapaci y 1 CD— No. Compartments Z PKG.TREATMENT PLT.E7 "/1 / 1 Method of Disposal Distance to nearest: Well.l;S.—•— Foundation_1:5 Property Line /n 0 LEACHING LINE E No. 8 Length of lines UU _ Total length/size./d FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS v Depth a � Sizr � NumberLt — SUMPS Distance to nearest: '.-Veil�C D Foundation a'�= _ Property Line DISPOSAL PONDS 1 hereby certify that I have prepared this application and th&t the work will be done In accordance with San Joaquin county ordinances,<tate 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, 1 shall not employ any person in such manner ds to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which th;s permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." Th., applicant must call for aujoauired inspections. Compete drawing on reverse side. Signed / _ Title: CL N L Dite: 7 — i FOR DEPARTMENT USE ONLY Area Application Accepted by 'G-%'' '�'�-"`- Date ✓ Date Final '' ✓ t «."�(. Date / Pit or Grout Inspectici by _. � l Inspection b `� . Additional Comments: ❑ Stk 466-67,1 ❑ Lodi 369-3621 ❑ Manttca 823-7104 ❑ Tracy 835-6325 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Haze.ton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT PEMITTED CR DECEIVED BY DATE PERMIT NO INFO CASH V Er,1324InEV.10,82 E-t�26