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S.W 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. Z 1/y//,,.'zfn�/D (/{/n��, ,,,A �� Job Address � ✓ � � UL� �YfLl7/Y/N'I Citi/'vu4�4�– Lot Sizay� PM Owner's Na J�/A�'dddddressss/�J�a C Phone ` r r r / , yk /E� i r ZyZ Phone `S�� Contras Address r License No. 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 [5-0-p en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications PI Public ❑ Other FI Delta Depth of Grout Seal Type of Grout ` I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ ,V Well Destruction ❑ Well Diameter Sealing Material (top 501 C DepthMaterial (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION EP ADDIT10 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Rest encs Commercial Other Number of living units: Number dr m Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �2v�No. 6 Length.of linesLAI) Tpal length/size V FILTER BED /7 ❑ _Distance to nearest: Well .�a Foundation_60 Property Line i 06f SEEPAGE PITS I I Depth Size Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 subcontracting 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 rfornia.,, _ The applicant u call for r uire inspections. Complete drawing on rever$' s/rL e 9 Signed X Title: / V l Date: FOR DEPARTMENT USE ONLY Application Accepted by �� CJ DateArea Z LPk or Grout Inspection by Date Final Inspection v�. ,- Date � Ifditional Comments: ./� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Semiges. 01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DU�,- AMOUNT REMITTED /' C KSH RECEIVED BY DATEr PERM/IT�'N/O. 4 EH 1124 IREV.Ii X5) I INr� 1 ' p t EH 1x-28 l e