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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 1 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address -'-34S A, 119kazyz� City Sn�e&7V4 Lot Size PM Owner's Name �� l, � Address � � �� /ol�t�.�S �2,C� Phone �� Contractor IyupDeft,62-S! W Address ' Z/_ZO 4&ZZ+_c D,�.Plzicense No.4Z(T4 e6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION J ?gK,01AV,1,!5lA4WFEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,V Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern _ Surface Seal Installed by Repair Work Done ❑ Type of Pump $Ue? H.P. Z— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION D (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ :No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 'Distance to nearest: 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 Sib Joagrin`county ordinances,state laws, and rules and regulations of the Sen Joaquin 1.9cal-Health District. Home owner or licensed agent's signatuie 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 tobecome 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 applicant must call for all;required inspections. Complete drawing on reverrsee a e. Signed ` Title: f GJ/o7 �1�i� Date: FOR DEPARTM T USE ONLY f �� Application Accepted by Date ` i'Area Pit or Grout Inspe t' n by Date Final I ction by Date [ /A�,d,.d�i�t�i�onal Commen l A-W , 466-6781 ❑ Lodi' 369-3621 ❑ Aanteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE } AMOUNT REMITTED CASH CK RECEIVED BY DATE PPEERMIT"NO. + EH 18-24(REV.1/e 5) L/" xp , O+ f EH 14.28