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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZEL T ON 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, i Local Health District. y { Job Address `Zto �J City Qr1CA_1tal�Lot.Size )D& _ PM Owner's Name Z 3_4 LA c n-jf 1131 Address P_P_ k_— Phone 4. Contractor �s= Address License No. Phone j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP i INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I 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 I'1 Public n Other N n Delta _ TDepth of Grout Seal k. Type of Grout- -1 rout•I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1 DESTRUCTION (No septic system permitted if public sewer is –available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms .» A Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑ Method-of Disposal Q Distance to nearest: Well `Foundation Property Line FF r � _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line J, SEEPAGE PITS 1-1 Depth Size Number SUMPS ❑ Distance to nearest:- Well` Foundation Property line DISPOSAL PONDS ❑ 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 Di§'trict. 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."Contractor's hiring or sub-contracting signature,,, certifies the f . g: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws o Cal' nia. The applic t st call for all requir d in pections. Co to drawing on reverse side. { Signed X Title A r,4 Date: J ✓/ FOR DEPARTMENT USE ONLY Application ted by / 'Date-- Area 6 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 FEE1 AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE /.'PERMIT•NEH 13-24 O. + EH 1028IREV.ii9sl