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a 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) j 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. 1 r Job Address —I D 4E zel L... h Ix'A - City V6d Lot Size PM �j 1 f,' / / f •yAddress _r ()C/ L. �/+L� Phone Owner's Name Lam— I a.� f 1 � S ! Address "� Gv��L La epi Phone I TYPE OF WELL/PUMP: NEW WELL ❑ ' = _ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION L3 --<- ,F` 'SYSTEM REPAIR ❑ OTHER I' DISTANCE TO NE PTIC TANK SEWER LINES DISPOS PROP. LINE FOUND AGRICULTURE WELL; THER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PR RE{ STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑aM a Well Excavation Dia. of Well Casing *� ❑ Domestic/Private ❑ Gravel Pack Tracy- t, F Type.of Casing Specifications Y f"I Public ❑ Other ❑ Delta , Depth of Grout�SeaI - ..Type of'G?oouI I Irrigation --Approx. Depth -I 1-Eastern s ! �Surfece Seal Installed by _ Repair Work Type of Pump = H.P•.--_--'~ �^^-- - State Work Done V p Well Destruction ❑ Well Diameter }� v" ,. Sealing Material (tap 50') � Depth s Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION L.) REPAIR/ADDITION I I . DESTRUCTION 1No septic system permitted if public-sewer is available within 200.feet.) 4 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ` a SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. 11 Method of Disposal Distance to nearest: Well r Foundation Property.Lirie LEACHING LINE ❑ No. & Length of tines Total tength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Number { {- ` SEEPAGE PITS i-I Depth Size ' ' '' `f - - +� SUMPS ❑ Distance to nearest: Well �.F-oundation 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 f 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 California." The applicant st ca for all requiro inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date 30 Area I Pit or Grout Inspection by Date Final Inspection by Date LO D Additional Comments: rZg 57r2 ❑ 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r.EH 1 00 6 43-24(REV.1�H5) ^" EH 14-2d