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d` 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 Ryles andARegulations of the San Joaquin Local Health District. Job Address z 'Si:'.�o Zig L PM Owner's Name Address l S, � `yLQZ�Phone 3� r' � c✓ �� Phone- Contractor�/g.�i�b�� __Address3—1 � �`Lf�+�-� icense No. _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION "0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WEL12PiTSISUMPS - INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "°Dia":"�f Well'Casing=�_ ._ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications- C-1Public ❑ Other EJDelta . Depth of Grout Seal Type of Grout j_ , ` ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by F j Repair Work Done ❑ Type of Pump.. H.P. State Work Done Well Destruction ❑ Well Diameter "Sealing Material (top 50�I j Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION A DESTRUCTION ❑ (No septic system permitted if public sewer is Q available within 200 feet.l w Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Wate-r table d. th ► SEPTIC TANK ❑ Type/Mfg Capacity No. Compartrints k nib PKG. TREATMENT PLT. ❑ Method of Disposal T l Distance to nearest: Well Foundation Property Line I LEACHING LINE No. & Length of lines U Total length/size FILTER BED ❑ Distance to nearest; Well Foundation Property Line + I SEEPAGE PITS ❑ Depth Size Number t SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all r1quired inspections omplete drawing on reverse side. f Signed X Title: ° }_ Date: r " FOR DEPARTMENT USE ONLY Application Accepted by n 1 Date �' Area Pit or Grout Inspection by Date Final Inspection by "Date S 3 7 ditional Comments: w Stk; 466-6781 ❑ Lodi 369-3621 ID Manteca 823.3-710.4 0-Tracy $35-6381 i plicant- Return all copies to: Environmental Health Permlt/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEtMIVNO. INFO CA5H ,C�W/1 .��,I�S/, + EH 13-24(REV.1/e5) �(J 7 � t FI /-� ov y EH 14 26 S