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APPLICATION FOR PERMIT SCANNED ZS SAN JOAQUIN LOCAL HEALTH DISTRICT No wv- Co.A gml\AoY 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 -V„„ p 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 E Lot Size Me) A 40 PM Owner's Name Lei r Address a � I rlpj 7 Phont Contractor. 1 f . Address 4 Q I-icense No. Phone f7 TYPE OF WELL/PUMP: NEIAPWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS L,FLD. - PROP. LINE FOUNDATION AGRICULTURE-WI=LL OTHER WELL PITS LIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ] ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationI Dia. of 1+ Casing EJ Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specificelltions ❑ Public ❑ Other 0 Delta Depth of Grout SealType of rout r km 13 El --Approx. Depth ❑ Eastern Surface Seal Installed by PIZ Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material'IBelow 50') , TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION INo 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 I Capacity No. Compartments PKG, TREATMENT PLT. ❑ +r ,arrwr�..r L Method of Disposal 777 Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines fiotal length/size. FILTER BED O Distance to nearest: Well��._ Foundation f1 Property Lire �• SEEPAGE PITS ❑ Depth Size ia0l tNumber SUMPS j 41 0 Distance to nearest: Well f 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." f! The applicant must c II for all required Tis9tions, Complete drawing on reverse side. `7 1 -e/ Signed X Title: C7�r Date: b� E F R DEPARTMENT USE ONLY r e. Application Accepted by -� }.-Dates-��^ � �^'ATea" Pit or Grout Inspection by Date Final Inspection by Date Additional Comment Cie GA ft" ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385\Y'ti 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 C$H RECEIVED BY DATE PERMIT-NO. - INFO + EH13-24{REV.tins) 3S--- /ODS 7 if 7-R0001 EH 1428 7