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Zw APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y` {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.a Job Address y-y ,f �r— CJO�� 'Aa/ rson A. /�Y � City C Lot Size t7 SG PM _ t Owner's Name t,ordo71 6 !+r ,4 Address #�T�Ox 7f� - Phone 8315 S � l' Contractor r Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ is 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public F1 Other I F1 Delta Depth of Grout Seal Type of Grout_ I I Irrigation --_-_.Approx! Depth I I Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction Q Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') —_ e TYPE OF SEPTIC WORK: NEW INSTALLATIONT REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ll'' Installation will serve: Residence X_ Commercial_ Other Y Number of living units: _1L__ Number of bedrooms_ j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK (Z Type/Mfg Capacity d No. Compartments Y RKG. TREATMENT PLT.. ❑ 1 Method of��Disposal C Distance 10 nearest: Well 4'd d Foundation Property Line—.-1- -`=— y LEACHING LINE 'V—No. & Length of lines " U� ( Total length/size j FILTER BED ❑ Distance to nearest: Well_' f Foundation Property Line ` SEEPAGE PITSIt Depth Size Number SUMPS ❑ 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. s 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, 1 shalt not i 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 ust call for all re ire ins tions. Complete drawing on reverse side. r / Signed X Title: OLD&tach Date: ZO FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area Z (2 Pit or Grout Inspection by Date Final Inspection by Date !/ Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE' AMOUNT REMITTED- CK CASH - RECEIVED BY DATE PERMIT-NO. INFO �J 'i.EH 13-24(REV.1/n5) /,} ;;7�. Y EH 14-18 ! lJ 0 y