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0c7 APPLICATION FOR PERMIT rz SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES T 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. `�� ,/ y �j��, Job Address �/2_67 `DVC -/�N! x, City i�,___._ Lot Size ) ` PM 17- Owner's Name Zkym Address 32-67 bL�Q�IV Phone go t Contractor Address 7,497 4,4 4, 44e No. 19 ISR2 Phone 3 �13a TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 0-1— DISPOSAL FLD..100 PROP. LINE [4 FOUNDATION _ � AGRICULTURE WELL OTHER WELL�� PITS/SUMPS 15b4 „� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �OD �Jl�n9 1:1 Industrial �d'�7pen Bottom ❑ Manteca Dia. of Well Excavation___ � Dia. of Well Casing 33 �- %w�'Domestic/Private [❑`Gravel Pack ❑ Tracy Type of Casing -- , , Specifications LUiL t F] Public M Other fl Delta Depth of Grout Seal ^] Type of Grout o I I Irrigation --Approx. Depth i I Eastern Surface Seat Installed by S .� ��-.�--- Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (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: Zialewake depth SEPTIC TANK ❑ Type/Mfg Capacit No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well;;��Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:/W ell Foundation Property Line SEEPAHE PITS 1 1 Depth 4 Size Number SUMPS# Cl Distance to ne est: 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 applican all required ' ctions. Complete drawing on reverse side. F Signed X Title: pate: 1 FO DEPARTMENT USE ONLY �7 Application Accepted by Date_ / Area Pit or Grout Inspection by Date -Z Final Inspection by Date >Sv Additional Comments: / 2 Z 212` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASE+ RECEIVED BY DATE �yPERMI7'NO. EH 13-21(REV.t/w 51 17