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APPLICATION FOR.-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' . Telephone (209) 466-6781 PM F 3 —Z- PERMIT EXPIRES 7 YEAR FROM DATE ISSUED s -. (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 o3scribed. 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 Regulzltions of the San Joaquin Local Health District. Job Address / Ste' -- - City Lot Size PM Owner's Name Tr - JZ—'� Addresses* � � Phone Contractors NameL E, L X reel_ License No. l 7�--- Phone TYPE OF WELL/PUMP: NEW WELL ❑_ 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 1 INTENDED USE _..—�_-..T TYPE OF WELL PROBLEM AREA CONSTRUCT4DN SPECIFICATIONS L1 � ❑ Industrial --- ❑ Open Bottom ❑ Manteca Dia. of Well Excavati6n ' f Dia. of Well Casing k ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. States Work Done Well Destruction *. ❑ Well Diameter Sealing Material (top 501 Y Depth _,Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic-system`permitted if public sewer is available within 200 feet.), Installation will serve: Resi encs LrCommercial_ ther '�- Number of living units: Number of b rooms Cha racter.of_soil.to adepth of 3 feet: I�1 1w"f\ "i Water table depth SEPTIC TANK-' ❑ ,Type/Mfg h. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of is o al Distance to nearest: Well Foundation_L._1;1Property Line .w LEACHING LINE Cll-'No. & Length-of lines _ •'Total length/size— FILTER ength/size FILTER BED ❑ "Distance to nearest: 4�Well Foundation Property Line `" d x '�' SEEPAGE PITS as -Depth J Size'- Number ' I SUMPS ❑ Distance to nearest $ 'Ail,,r F), Foundation_—,j Property Line DISPOSAL PONDS ❑� I hereby certify that I have prepared{his application and that'.the work will be done in accordance wiarr th STJoaquin county ordinances, staie.laws and -� rules and regulations of the SanJoaquin Local Health District` y Home owner or licensed agents_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 ethat in the performancebbf the work for which this permit is issued, I shall employ persons subject to workman's compensa- k' laws of California.".+ t I - The appllc ust all far all (red ii ctio Complete drawing on r verse sid Title: Date:' FOR EPARTMENT USE ONLY g e Application'Accepted byI_ A Date�� Area p Pit or.Grout Inspection by ate Final Inspection by Date Addi lorsal-Comments: ❑ Stk 466-6781 ❑"Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I z Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH { * T13-24 IREV.101831 ., -..»�..�.. --..:�`..,Aa.......-. �p�z J w �10�o l EH 14-25