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APPLICATION FOR PERMIT n� SAN JOAQUIN LOCAL HEALTH DISTRICT � v 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 welllpump and the Rules and Regulations of the San Joaquin Local Health.District. Z J/ AVE �r�J �,�/ Job Address 2 y / `` Ay E City J r K . "Lot Size QPM G fl CY 'fA _� 1 L U 'I F— irt�Fy I r J �� _ Phone � ! � 63 39 Owner's Name Addres/s ContractorLZ E Address L r 0!T License No. Phone g--1:3 TYPE OF WELL/PUMP: NEW WELL LJ 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 ❑ Industrial ElOpen Bottom LJManteca Dia. of Well Excavation Dia. f Well Casing (, ❑ Domestic/Private El Gravel Pack Ll Tracy Type of Casing Specifications 71 Public Cl Other F1 Delta Depth of.Grout Seal Type of Grout --- I I Irrigation T-Approx. Depth l I'Eastern Surfaco'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 I] REPAIR/ADDITION 1.1_DESTRUCTION i NQ& septic system permitted if public sewer is ailable 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line t 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY },{j Application Accepted by _ Date 3 .2 /r E7 Area 1�2p Pit or Grout Inspetion InDate Final Inspection by z, Date l b, U f Additional Common II[ ❑ Stk 466-6781 ❑ Lodi 3 -3621 ❑ Manteca 623-7104 ❑Tracy 835-fi385 w. 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 CASH RECEIVED BY DATE PERMIT"NO. INFO f� + EH 13-24(REV.1iN5) ✓ Ila � � �/ ! ,� ® � • EH t4-26 ��// 'l✓