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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. e Job Address L 7 J!YAC ken City SIAA) Lot Size pM Owner's Name �.�LIV�t� Ctv4 � Addresses 40�r �A firs' G1/GL. Phone � GL Contractor ��1M Address �-& Ifs-: '{P License No Z 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S l� ❑ Industrial 15-Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I,1 71 ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing L Specifications vV FI Public mft; _ th� _` - 0 r ❑ Delta Depth of Grout Seal Type of Grout I ) Irrigation Wt u W.Approx, Depth I I Eastern Surface Seal Installed by lI'!A ~— Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to aof 3 feet: Water table depth SEPTIC TANK ❑ Type Capacity No. Compartments PKG. TREATMENT PLT. Cl 001f Distance to nearest: Well Foundab Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance rest: Well Foundation Property Line SEEPAGE P I I Depth Size Number SUMPS Ll 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 wprnia." 1 The appl' an[4m3l call for all r u'ed i e ns Complete drawing on a �a��rse--sidyye. .may] ry Signed Title: L�GfiGt�M- //,(2/L. G �/Z Date: OR DEPARTMENT USE ONLY / Application Accepted by Date /Z/ Z 2/& 1�' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMITNO. . EH 13-24 IREV.rix 51 EM 10-2e ?>S , 00 Z7 C C�— /'1Z./ �"—'7� � ( — J