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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 7 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 Ryles and Regulations of the San Joaquin Local Health District. " Job Address r % J City A- Lot Size PM Owner's Name M1'1ZV C Of--fA -6 i ll. DAddress Ll IR'W?'L;'- _= Phone 1 Contractor It rr -Address'0003 �1,i� License No. 7 Phon*39 TYPE OF WELL/PUMP: NEW WELL ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth I', ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump _ H.P. . ] v State Work Dane J -. Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC.WORK;, NEW INSTALLATION El. REPAIR/ADDITION ❑ DESTRUCTION (7 (No septic system permitted if public sewer is \13 " " �� 'J -" VJ I'll I available within 200 feet.) S �\Installationmill serve: Reside �nce Commercial� Other Number of living units: f Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity f No. Compartments y PKG. TREATMENT PLT. ❑ � t Method of Disposal j r I Distance to nearest: 1l,,1r, Well a Foundation � � Property-gine r, r LEACHING LINE ElNo. & Length of lines ' "� �" ; Total length/size FILTER BED ❑ Distance to nearest: 'Well Foundation Property Line.,, SEEPAGE PITS ❑ Depth Size Number SUMPS 1 Distance-to.nearest:_Well. . _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. l 1 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." i The applica ust call for all a wired 'nspections. Complete drawing on reverse side. Signed Title: _&J11a9A _- p D ; �" , FOR DEPARTMENT USE ONLY Application Accepted by Date 7r / g4ref,"Ai a ' Ji Pit or Grout Inspection by 'Date S Final Inspection Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385G;+ 4 Applicant- Return all copies to: Environmental Health Per Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., Cfk-n— FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO +EH 13"24(REV.1/85) 11 l S EH 14-28