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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 Rules and Regulations of the San Joaquin Local Health District. Job Address % "'� '� City Lot Size PM Owner's Name ZAI , res @ < '�T-�' Phone 005 "3 7 Contractor � Address License No. C Y-+Phon 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy ;, Type of Casing Specificatiohs ❑ Public ❑ Other ❑ DbIta, Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern �Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-10-.,DESTRUCTION ❑ (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 LEACHING LINE JT No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well �— Fo�undali�-n, " Property Line SEEPAGE PITS � Dept Size ` Number SUMPS ❑ Distance to nearest: Well Foundatl$ Pro SUMPS 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 fttricL ' Home owner or licensed agent's signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject tp workman's compensation laws of California."Coptractor'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 stun employ persons subject to workman's compensa tion laws of California." The scan at�Falll—re'q�ired foe nspe ions. Complete dravling on reverse side. Signed Title: �iI7 �-�/�s� Date: FOR QWARTMENT USE ONLY 'i Application Accepted by r'I Date ��' Areas y Pit or Grout Inspection by Date Final Inspection by 1 Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CK 9 CASH RECEIVED BY DATE PERMIT NO. INFO ( –t)�6 + EH 18-24(REV.1/e 5) —7� EH 14-28