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r +� APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. /7!7 LEJ . Job Address C• ('f Y • R 3a��ty 1� PM City Lot Size Q Owner's Name Address 10 E 4 Phone Contractor Address 3� O� License No. 3t-I0�`` Phone�'� TYPE OF WELL/PUMP: ITG WELL WELL REPLACEMENT ❑ DESTRUCTION Ll Oe! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ID STANCE 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 tt ❑ Industrial ❑ 0 n Bottom LJManteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic rivate- [Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public ❑ Other ❑ Delta Depth of Grout Seal "t3 Type o ro 1 I I Irrigation Approx. Depth lr'Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump ^ H.P. State Work one Well Destruction ❑ Well Diameter Sealing Material Itop 501 f Depth Filler Material IBeIOw,50'1 I Z,—r TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) \ Installation will serve: Residence_ Commercial_ Other J Number of living units: Number of bedrooms 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 ` 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 perilirmp in such manner a�bec ubject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the _ n I certify t t ance of the work for is�.id. I shall employ persons subject to workman's compensa- tion laws of The applica st call fore i dins tions. Complete drawing on re ise . Signed X Title: � � ST Date: 7 "10— rJ FOR APARWENT USE ONLY h Application Accepted by Date �� Area Pit o Grou Inspection by t ate — Final Inspectio by Date F V 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 83 -6385 Applicant- Return all copies to: Environ ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 13Y DATE PERMIT NO. INFO p 7 + EH 13-24(REV,1i85) EH 14-2a