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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 i 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 ZZ420001/ City 7 Lot Size} PM ., Owner's Name ^*' -Address= - Y 3- Phone 6 '% + Contractor's Name fY 4SAIVSLicense No. iJ phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Privateer -❑ Gravel-Pack -[]-Tracy-.-. ----Type of Casing -' -Specificatid-ris TM� �x y 0 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal, Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.p. -.-,�.�, ... State Work Done WellZestruction ❑ Well Diameter -Sealing Material (top 501) r Depth I ( elow'$0') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR/ADDITI -'DESTRUCTION ❑ (No septic system permitted if public sewer is IS available within 200 feet,) p Installation will serve: Residence'— Commercial— Other-C✓1/ C7 ^ Number of living units:= Number of bedrooms Character of soil to a depth of 3'feet: _ Water table depth SEPTIC TANK i Type/Mfg ?' Capacity-/430A2- No. Compartments ' PKG. TREATMENT PLT. ❑, Method of Disposal Distance to nearest: Well Y T Foundation 2 d Property Line -Z Q LEACHING LINE V�--No. & Length of lines Total length/size X 7 Q FILTER BED ❑ Distance to nearest:' Well� e /t/ Foundation's� Property Line_ 1: f i s SEEPAGE PITS ❑ Depth Size .Number x SUMPS ❑ Distance to nearest:E Well Foundation ,Property Line DISPOSAL PONDS ❑ I s hereby certify that I have prepared this application and that th`e 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 performanca 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 em tion laws of California." Ato y persons subject to workman's compensa- The applicant all for all required inspections£ Complete drawing on raver Ida. Signed Title.. Date: FOR DEPARTMENT USE ONLY r i Application Accepted by Date (D �l Area N 01 Pit or Grout Inspection lay Date FiJy nal Inspection by Date`l, z� Additional Comments: i � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ; i Applicant- Return all copies to: EriUi►onmental Health Permit/Services-1601-E-Hazelton Ave..--P.O-Box-2009;-Stk.,-CA-95201--- 1 j IEEE AMOUNT DUES' 1 AMOUNT'REMITTED CK ' RECEIVEO.BY � �' CASH DATER IIJPERMIT N0. - 83 + EH T324IREv.1011 0 4 1�j1j�1 EH 1426