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APPLICATION FOR PERMIT II 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) pplication 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 at Llgocal Health District. Job Address — City Lot Size pM S Owner's Name ��K a its Address S7 LE R1!Cl�, i O Phone L �ub;. Qu�rJs �oas� - 6 Contractor's Name • _ License No. Phone TYPE OF WELL/PUMP: it NEW WELL ❑ WELL REPLACEMENT-❑ DESTRUCTION i� PUMP INSTALLATION D SYSTEM REPAIR n OTHER ❑ I. DISTANCE TO NEAREST: SEPTIC TANKq. —_ SEWER LINES _ DISPOSAL FLD. PROP. LINE { FOUNDATION _ AGRICULTURE WELL _ OTHER WELL __ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I, G Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation_ Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack L; Tracy Type of Casing_ Specifications ❑ Public 1-1OtherD Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by_ i Repair Work Done P Type of Pump _.�— H.P. _ State Work Done ' Well Destruction Well Diameter Sealing Material (top 50') Depth'—-- Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Li REPAIR/ADDITION C DESTRUCTION ❑ (No septic system permitted if public sewer is Navailable within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: I1 Number of bedrooms_. Character of soil to a depth of'13 feet: _Water table depth SEPTIC TANK I Type/Mfg Capacity_ No. Compartments _. PKG. TREATMENT PLT. L Method of Disposal I M Distance to nearest Well Foundation—_ Property Line LEACHING LINE ❑ No, & Length of lines _.. . _ Total length/size FILTER BED 171 Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS ❑ Depth _ Size _ Number ' SUMPS ❑ Disiance to nearest: Well Foundation Property Line . DISPOSAL PONDS Ll �� 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 mannei as to become subject to workman's compensation laws of California."Contractors 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 Califom• �:- Thb applica3 mus II for all req) red inspections. Complete drawing on ppreverse aide. V Signed ` Title: �r1` t Date: FOR DEPARTMENT USE ONLY Application Accepted by Date — Area / Z Pit�or Grout Inspection by Date Final Inspection by ClrGz�G�� Date —S' Additional Comments: II ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623.7104 C Tracy 835.6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;`Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE 1 PERMIT'NO. CASH crush +�3-B�f S'q-3W + EH 13-24(REV. 101,83) � Hi 1426,1 �_ 1