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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZELTOIV AVE., STQCKTON, CA 1,17 f Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUELD 1 (Complete in Triplicate) SE ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inti,�i) ewtibflZ'h�re}h7Q'sgriletl;;F�fis3�l plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and thebs Ru ;ar�d Cte941�tiQtis;of,tha San Joaquin t-ocal Health District. 1 Job Address 92r f city-Lod, Lot Size PM Owner's Name `r� C f� Address / � � �� Contractor l/'/�' � Address 0 2 Lice No. 23`—5 Phone 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 4 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 omesficlPrivate Cl Gravel Pack ❑ Tracy Type of Casing Specifications (� Public ❑ Other n Delta. De'�th of Grout Seal T I Type of Grout - I I Irrigation —.Approx. Depth `p i I Easters Suiface Seal Installed by t�� Repair Work Done C7 Type of Purnp SkIl7 _ H.P. f State Work Done a -rCT74 Well Destruction 3 Well Diameter � Sealing Material )top 50'I Depth Filler Material feelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 HE Alft/ADDITION € I DESTRUCTION I I (No septic system permitted it public sewer is ` available within 200 feet.) Installation will serve: Residence_ Commercial I Other Number of living units: Number of bedrooms i Character of soil to a depth of.3 feet: f Water table depth k SEPTIC TANK D Type/Mfg Capacity No. Compartments i' PKG. TREATMENT PLT. ❑ 1 Method of Disposal I� ll Distance to nearest: Well Foundatim, Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well_ ,Foundation Property Line t. SEEPAGE PITS I I Depth Size ff' Number SUMPS Ll Distance to nearest: Well T}Foundation Property Line I DISPOSAL PONDS ❑ I 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 componsatiort 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- lion laws of California." The applicany7/;st call for all required inspections. Complete }drawing on!reverse side. (/ Signed X . /n' l� 'L �L''✓ /z�tiTitle: ��r' Date: i1 �^ �f o FOR DEPARTMENT USE ONLY Application Accepted by r ! i Date `r` Area Pit or Grout Inspection by Date _ Final Inspection byLL� 1 Y'�9 — Date II Q Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk-, CA 95201 FEECK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. . EK 13-24 IREV. PLATE 20