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APPLICATION FOR PERMIT r •-.ti .'moi f S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) A 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 rf i■ Q � ��GGA City �t Size PM Owner's Name Address 2.140 PZZ444 mA Phone Contractor dress license No Phone tZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PU INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI ANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Mantec Dia. of Well E pia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy asing Specifications ❑ Public ❑ Other a Depth of Grout Type of Grout ❑ Irrigation Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance,to nearest: Well .,x "f=oundation Property Line '- LEACHING LINE ❑ No. & Length of lines *= * y Total length`/size �. f FILTER BED ❑ Distance to nearest: Well Foundation Property Line y tl SEEPAGE PITS i ❑ Depth Size Number SUMPS ❑ . Distance to near es%t:-�...�.Well" •--Foundation " Property Lin" 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 becomwsubject 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." 1 The applicajut must call for all r uired i 1ppections. Complete drawing on reverse side. i w s Signedx X. l Title: date: ILI FOR DEPARTMENT USE ONLY Application Accepted by ' Date C Area L - l�Pit or Grout Inspection Date Final Inspection by Date Addition Comments: ❑ Stk"',466-67811 ❑ Lodi 369-3621, ," «❑,Manteca S'M-7104 . ❑ Tracy 835-6385. t%- .f.,� Applicant - Return all copies to: Environmental.Health PermitJServices,16dl E.✓Hazelton Ave.,,P.'O. BoxC 2009, Stk., CA'95201 ,r I FEE-� �, AMOUNT DUE "AI410UNT REMITTED C RECEIVED BYF DATE PERMIT NO. INFO SH + EH 13-24 fREV.1/8 , s 3S EH 14-2840 XR. . a