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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 456-6781 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 ZF6� � f_ City -f 7w-- Lot Size PM Owner's[Name /V// G �yHlr k `+4ddress .�/T�� Phone Contractor 01 /t/3' �A Address License No. {�Phone S F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION P �QF_,oaX4e,6,,WEZ*T EM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE ' - TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ' - � ` —' —❑-Industrial—❑-Open•BottomA ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications O Public ❑ Other 4 ❑ Deita Depth of Grout Seal Type of Grout i d ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by tt Repair Work Done ❑ Type of Pump 5013 H.P. State Work Done j Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) pro Installation will serve: Residence— Commercial— Other 6 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.�O t Method of Disposal 1 ! f Distance to nearest: Well Foundation Property Line i rl LEACHING LINE ❑ No.;& Length of'lines Total length/size ,FILTER BED E3 Distance to nealsit: Well Foundation Property Line .� SEEPAGE PITS ❑ Depth j Size Number A SUMPS 5 91 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS rt ❑_;.. . :: i hereby certify thai l-have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statevlaws,,and rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agents signature certi ies 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_marner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ! cart es the follo4ving:1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workm6n's1domoense- tion laws of California. '} v The a$plicant tp II r pections. Complete drawing on r ver ide. l Signed i i Title: � // � � Datil OR DEPARTMENT USE ONLY Application Accepts Date _ `Area Pit or Grout Inspection by Date Finl�n'pe`cton by Data b +3a — Aaiartional omments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 0 Applicant- Return all copies toi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20b9;Stk., CA 01 t f — ' t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH 11 y + EH 13-24IREV.i/a5) '"� rte. ,��,�-;, gb i EH 14-28 ----]