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APPLICATION FOR PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZELTON AVE., "STOCKTON, CA � Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM-DATE 'ISSUED (Complete in Triplicate) o ' � 7 w C.3ti• % n . 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 Ryles and Regulations of the San Joaquin Local Health District. " Job Address 006 06Ar4' Cit,` J T4`i Lot Size PM eo1 /V. d TZ-01-0 Name - Phone / f�11 Contractor 0, A • N K'ZTS It!-5&)SAddress License No. 602V I Phone Z 415�g01;04 % TYPE OF WELL/PUMP: ,. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP_INSTALLATION ❑ SYSTEM REPAIR, ❑ OTHER ❑ j 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/Private ^— ❑ Gravel-Pack- .� `❑Tracy""' wType of Casind Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal. $Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by l Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 {{ Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve:£i Residence Commercial_ Other _ l Number of living units:- ` Number of bedrooms j Character of'soil to a depth/of 3 feet: Water table depth SEPTIC TANK". v�� Capacity _ No. Compartments f PKG. TREATMENT PLT. ❑ A, ` Method of Disposal ' Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. &-Length of lines Total length/size FILTER BED ,� ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Oepth j Size Number, j t SUMPS ` ,'❑`—Distance to nearest: Well Foundation_ Property Line E a 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 I rules and regulations of the San Joaquin Local Health District. t ' V 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 I 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;`]shall employ persons subject to workman's compensa- tion laws of Califor The applicant t c I for all r in pe ons. Co plete drawing on reverse side.i Signed ;Title: r Date: G FOR DEPARTMENT USE ONLY p Application Accepted b _ - Date Area Pit or Grout Inspection Date Final Inspection 6v- Date�u.._.__ Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 389-3621 ❑ Mant 823-7104 ❑ Tracy 835-63% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY .,. DATE PERMIT'NO. + EH13-24(REV..V $.s 51 "0 lam. - -. .. W p EH 14-26 Q S