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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED j (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. / / City t� Lot Size PM Job Address Owner's Name I C Cz' � ddress Phone P Contractor /S Address 9$ N (� CiJA License No.�__.._-- hone TYPE OF WELL/PUMP: NEW WELL IDWELL REPLACEMENT ElDESTRUCTION ❑ `y� .PUMP INSTALLATION-El- -- 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 Dia. of Well Casing ` ❑ Industrial... --- -F1 Open Bottom_ 1]-Marzteca Dia. of Well Excavation \(� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Type of Grout — ' Delta Depth of Grout Seal Yp _ �— i 1 Public FI _ I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well,Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) r'. TYPE OF SEPTIC WORK: NEW.INSTALLATION I:I REPAIR/ADDITION DESTRUCTION I 1 alvailablerwthin 200 feet.system I if public sewer is ? Installation will serve: Resider4ce Commercial +Other Number of living units: Number of bedrooms : �V�J✓�` r Water table depth \] Character of soil to a depth..of 3 feet: >�L^Goye2tTt Capacity_ O No. Compartments SEPTIC TANK >61-Type/Mf- Method of Disposal PKG. TREATMENT t PLT. ❑i 3 Distance to nearest: Well Foundation Property Line LEACHING LINE 1 ❑ No. & 4ength of lines �i Total length/size r I � I `A`�t� � �: -Property Line FILTER BED t ❑ 'Distance to nearest: yWell_ .� Foundation~ SEEPAGE PITS I I I Depth t Size Number SUMPS P, Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F f I hereby certify that I have prepared'this application and that the work will be done in accordance with San Joaquin county ordinances, state Yaws, and rules and regulations of the San Joaquin Local Health Diktrict. Home owner or licensed agents 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,1 shall employ persons subject to workman's compensa F tion laws of California." r The applicant m s call for I required inspections. Complete drawing on reversesae. ......�" Title: Date: Signed X R DEPARTMENT USE ONLY Rate � Area Application Accepted by a'Ji Pit or Grout Inspection by t Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 Ll Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE CK RECEIVED BY DATE PERMIT'N0. INFO MOUNT DUE AMOUNT REMITTED CASH -h (}�h t 4 I +.EH13-24IREV."/H 51 Grow D �� EH 1429