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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address ZY0 W City Lot.Size PM Owner's Name Address � �5' Q Phone y ! Contractor 661.ar Address License No. Phone TYPE OF WELL/PUMP: WEW WELL 'WELL REPLACEMEN `❑-, _ , DESTRUCTION ❑ I MIR-INSTALLATIONREPAIR- t - ' "` SYSTEM -❑.-.,,,,:�--.,,_,._,OTHER,©.M al � DISTANCE TO NEAREST: SEPTIC TANK /De � SEWER LINES 0d(1�-h DISPOSAL FLD. PROP. LINE IS FOUNDATION AGRICULTURE WELL OTHER WELL��-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial I ,'-Open Bottom ❑ Manteca Dia. of Well Excavation " Dia.-of-Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S �� C _ Specifications *Otj lif"1 Public . /4 F Other Cl Delta Depth of Grout Seal /�Q a Type of Grouter e.�Rir/ _ ¢t[Irrigation !'OcaT'P+� �.ApproK Depth l l Eastern Surface Seal Installed by �` 4!f e _ Repair Work�one Ll . Type of Pump Zej H.P. 7Q State Work Done_ 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth i Filler Material (Below 50') �y TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system-'permitted if public sewer is s available within 200-feet.) Installation will serve. Residence_ Commercial Other Number of living units: Number of bedrooms �—J { Character of soil to.a depth of 3 feet:Ii Water table depth ! SEPTIC TANK .❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ J Method of Disposal U Distance to nearest: Well Foundation Property Line f LEACHING LINE � ❑ No. & Lerrgth of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 'Distance a to nearest:' Well''1"'"`^'°^"^ Foundation` --- -.Pro e pray Line...-- .. ° DISPOSAL PONDS ❑ I �t 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 lR"„t 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.” f ' >The applicant must call for all required ins pppections. omplete drawing an reverse side. w; Signed X Title: Date: /,.7- R - DEPARTMENT SE ONLY Application Accepted by Date Area Pit or Grout Inspection-b Date'?t�fad� ,Final Inspection In Datea:P� Additional Comments: ❑ Stk 466-6781 q Lodi -3621 ❑ Manteca 823-7104, r ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services' 601 E, Hazelton Ave., P.O. Eloi 2009, Stk., CA 95201 / i INFO , AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO.. +.EH 13.24 IfIEV.t h 51 EH 14-26 6