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i 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. Job Address �I i! I City Lot SizeCL1(�J �M Owner's Name dress , . -- - Phone Contractor's Name cense No. Phone 7� ` `� / TYPE OF WELL/PUMP: NEW WELL L7 WELL REPLACEMENT ❑ DESTRUCTION ❑ C f PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. # PROP. LINE FOUNDATION J~ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS .. ❑ Industrial � D Open Bottom DN1anteca Dia. of Well Excavation � Dia, of Well Casing F1 Domestic/Private ❑ Gravel Peck SD.TracyType}.of Casing Specifications � [I Public D Other } El Delta Depth of Grout Seal Type of Grout ❑ Irrigation I _Approx.'Depth LJEastern Surface Seal Installed by11 e ' Repair Work Done D Type of Pump H.P. - _ '?; r'(State Work Done 11 Well Destruction ❑ Well Diameter_ I Sealing*Mate'rial (top-501 r 1 Depth I : Filler Material(Belo ') ! TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted H public sewer is I"9 available within ZOD feet.) O Installation will serve: Resi enceXl Commercial ther Number of living units: Number of,bedroom, Character of soil to a depth of 3 feet:)I IN Water table depth SEPTIC TANK } Type/Mfg Capacity No. Cort partments� _ PKG. TREATMENT PLT. ❑ Method of o�aI k '' t Distance•toi nearest:.' 1N Foundation _ Property Lin e LEACHING LINE r No. & Lon g h of lines t i Total length/size ff FILTER BED D Distance tol nearest: Well f Foundation Property Lie a >i I # n, SEEPAGE PITS I C Depth Size 1 Number # �' SUMPSDistance to nearest: Well Foundation Property Line DISPOSAL PONDS C I f I hereby certify that 1 have prepared this application and that the work will be done''n 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,certifles 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 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 perforinance of the work for which this pe;it is issued, I shall employ persons subject to workman's compensa- tion laws of Californl ' I t f , The app) u c I f re ire G. Co let awing o se sidle. ' L, Signed t Title: Date: 1 FOR DEPARTMENT USE ONLY Application Accepted by Date Area e` 1I4 ` v Pit or Grout Inspection by 1 Date (.Final Inspection by Date Additional Comments: I 1 !a/ D Stk 466-6781, ❑ Lodi 369-362T ❑ Manteca 823-7104 ❑ Tracy 8.35-6365 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201,. )NFO FEE AMOUNT DUE AMOUNT REMITTED CCK# RECEIVED 9Y DATE PERMIT"No. EH 14-21(REV.,rrasl Z!5'O° EH ,4-za