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' APPLICATION FOR PERMIT >� SAN JOAQYIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,, (Complete .in Triplicate) h Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This lapplication 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, v.• �: Job Address / / Z.` City d4�2 Lot Size PM �J Owner's Name ZILE& Address � � �� % PhoneJ 6q n II 7 r Contractor��56 ��[[{(eC D��-I Or", � nse No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER �JC.�Ld,e17;7/ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. . PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __.__Ap'prok. Depth ❑ Eastern Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done �f�47�'f �J Well Destruction ❑ Well Diameter •Sealin ra op 50'1 0 I� Depth _Ed e ow 50'1 —tS:E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public 'sewer is r/ I available within 200 feet.} 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 SEPTIC TANK ❑ Type/Mfg Capaci No. Compartments I p PKG. TREATMENT PLT. ❑ Method of Disposal .1 _. Distance to nearest: Well Foundati n Property Line 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well o d Property Line ^ SEEPAGE PITS ❑ Depth Size Number d SUMPS ❑ Distance to nearest: Well Foundation Pr Li DISPOSAL PONDS ❑ �. 1 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. ;I 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."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 workmari's compensa- tion laws of California." The applicant must call for all required inspe . Complete drawing on reverse side. Signed Title: Date: USE ONLY Appli ation Accepted by Date `— / Area i Pit or Grout Inspectio y Date Final Inspection by DatelF� �7 Additional Comments: ❑ Stk 466-6781 ❑ odi -3621 ❑ Manteca 823-71W ❑ Traef 835-6385ii Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk , I FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT N0..F INFO + EH 13-24fREV.1/e51 S [r/[./ �� , <D.> 3)<„y`O / ..W7 23 I °' EH 1428 -•. � r 1 {