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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 p�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V1 (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. f �&l � r Jeb Address �„ .,� City t Size PM Owner's Name __..� Address r AD IL❑ Jr*.��►i 1.C1`ZA^+ Phone Contractor �� JO. LwAddress License Na5l ffay—I Phone / 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy — —Type.of Casing— Specifications R Public n Other E-1 Delta Depth of Grout Seal Type of Grout I I lrrigalion _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dona,_. :Well Destruction EJ Well Diameter Sealing Material /top 50'1 Depth Filler Material (Below 501 nTYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION { I 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 C� SEPTIC TANK ❑I Type/Mfg Capacity No. Compartments �1 -e"PKG. TREATMENT PLT. ❑. Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE ❑. No. & Length of lines Total length/size .i-FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line . DISPOSAL PONDS C7 v`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 mu all for all required inspections. Complete drawing on-reverse side. ,r .eJ Q Signed �- Title: � Date: �r/ 3 FOR DEPARTMENT USE ONLY .WApplication Accepted by Date 5- Area �p r Pit or Grout Inspection by Date Final Inspection by Date A t� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca B23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + EH 13-24(REV.r/As) EH 14-2a t