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APPLICATION FOR PERMIT �j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA v� Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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 r 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 21 Z r City e- Lot Size -5--Ac- PM 'ter Owner's NameAddress Phone -ZAN .41 yaj Contractor X' _ ` Address License No..a1 f Phone d- ' TYPE OF WELLY UMP: NEW ELL WELL PLACEMENT ❑ DESTRUCTION ❑—,,,_ ` PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' - r� I ❑ Industrial ❑ Open Bottom LIManteca Dia. of Well Excavation J ` Dia%�of Well'Casing Domestic/Private Gravel Pack 17 Tracy Tracy Type of Casing 1l' Specifications 'k 1`1 Public ❑ Other . CI Delta Depth of Grout Seal S Type of Grout I I Irrigation ;tyo..Approx. Depth l l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pumper H.P. State Work Doe_ Well Destruction ❑ Well Diameter Sealing Material (top 50') �G Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence— Commercialb 'Other Number of living units: _ T 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 I Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PUTS I I Depth Size Number SUMPS ❑ Distance to nearest: We t 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. i 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 k 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- tionlaws of Calif nia." The applicant t call for all quired inspectigns. Complete drawing on revs a side. Signed X Title: 1 Date: FOR DEPARTMENT USE ONLY q�rt Application Accepted by Date ��^ 1 V Area Pit or Grout Inspection b Date ` s Final Inspection by � Date 11 Additional Comments: �J " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton i Ave., P.O. Box 2009, Stk., CA 95201 r i FEE - 'AMOUNT DUE AMOUNT REMITTED _ C SH RECEIVED BY DATE PERMIT'NO. INFO r;EH 13-24 iREV.1/es 51iyo: f'zp— / -/il;, EH 14-26