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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. Job Address 14 -� ? W I ____ ,i, City Lot Size Owner's Name ftp P! set e4 213P/a�Jd QL. e.N Address 16 :7 -7 LA. lam_` 4 r-, `QPhone Contractor LeA #-A 615riith*--Address �� / �L�� i!rs-�� i�c'��1 License Phones TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION 17 PUMP INSTALLATION C SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ..... _.......... .... .... ____ DISPOSAL FLO. PROP. LINE - i FOUNDATION AGRICULTURE WELL _.__._ ___..__. OTHER WELL_ PITS/SUMPS INTENDED USE L] Industrial 0 Domestic/Private I' I Public M I I Irrigation Repair Work Done LJ Well Destruction ❑ I I TYPE OF WELL G Open Bottom C Gravel Pack ❑ Other ____,.Approx. Depth Type of Pump Well Diameter Depth _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ .........................._. _..____ &a. -of n Manteca Well Excavation ❑ Tracy Type of Casing..._ l Delta Depth of Grout Seal L I Eastern Surface Seal Installed by H.P. State Work Done . Sealing Material (top 50) __.._.... ...... _.........._............_ .... _.......................... Filler Material (Below 50') ____ Dia. of Well Casing Specifications Type of Grout PM TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION hA- DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence .l-- Commercial _ Other Number of living units: LNumber of bedrooms Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK Cl Type/MfgCapacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No_ & Length of lines — Total length/size— FILTER BED LJ Distance to nearest: Well _�" Foundation Property Line 1 SEEPAGE PITS I I Depth r_e _. _........ Number .- .. i ,,SUMPS Distance to nearest: Well Foundation Property Line a _ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. t 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 suh-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 California." -The applicant must call for all required inspections, Complete drawing on reverse side. ,"Signed X WA Title: __4 - ____ Date: .- .. „ / FOR DEPARTMENT USE ONLY Application Accepted by. ...__ .. _ ........ ., ___.. ...... _ Date Area 1.3 Pit or Grout Inspection by Date Final Inspection by Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 G Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH 1324 (REV. r i n a EH 11.26 FEE INFO AMOUNT CLUE AMOUNT REMITTED CASH CK it RECEIVED BY DATE I PERMIT' NO. -70 ov I -`