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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i 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. Job Address :5:,Z�r� • �� ✓/Al - City C &41 Lot Size // PM Owner's Name �� Address ZEV/& _ Phone I j Contractor S-e– Address License No. Phone TYPE OF WELL/PUMP: NEW WELL:❑- y WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL= OTHER WELL PITS/SUMPS p ' 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 Type of Casing Specifications (-1 Public (7 Other ❑ Delta Depth of Gkout Seal Type of Grout I 1 Irrigation _-Approx. Depth 11 Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRYADDITION l I DCSTRUCTIONK INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ , Commercial— Other-- Number ther -Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg F _Capa`city• No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property fine 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 l rules and regulations of the San Joaquin Local Health D%i trict. '4 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 planner 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, l shall employ persons subject to workman's compensa- P .tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X�,r.Z Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by all Date /1Jj r /Area y Pit or Grout Inspection by Date Final inspection by - Date /,F # ! L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'NO. t.EH 13-24IREV.1./1451 i' �J I� EH 14-2e