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4ZA APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Rules and Regulations of the San Joaquin Local Health District. Job Address /0 �� ' �� 5� City -��' Lot Size �� _ PM Owner's Name � � d` � �� 0C Phone Address' �, �� " `� a Contractor Address License No. Phone TYPE OF WELL-/PLLW-r---_ —NEW-WELL- 0 -..- _ WELL REPLACEMENT D- -. _ _0ESTRU4GT4ON 0- PUMP .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE —TYPE—O.F.—WELL PROBLEM AREA CONSTRUCTION SPECIf[CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout SQal ' L' Type of Grout . I I Irrigation --Approx. Depth t I Eastern Surface Seat InsWied by _ Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter , Sealing Material (top 50'1 _ ,,Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION t I (No septic tem permitted if public sewer is available wit in 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedro02;,_ !Z'� y Character of soil t8 a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 4100 No. Compartments PKG. TREATMEN PLT. ❑ Method of Disposal Distance to nearest: Well t f Foundation Property Line LEACHING LINE' El No. & Length of lines �,� Tonal length/size FILTER BED ElDistance to nearest: Well CL Foundation SLi _ Property Line /Q r SEEPAGE PITS I I Depth Size _ Number SUMPS Cl Distance to nearest: Weil 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 appfi ust call frequired inspections. pletq drawing on reverse side. Signed X Title: 7� l.� Date: � - d FOR EPARTMENT USE ONLY ,I Application Accepted by Date _/ Area ` 3 Pit or Grout Inspection by Date Final Inspection by&t. 22_ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 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 RECEIVED BY DATE PERMIT NO. INFO EH 13-24(REV.1/x 5) EH 14-26