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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. t Job Address ;2r �� City Lot Size PM ,y Owner's Name lza Address Phone Contractor `U-4!� •Address �e License No..'22irZ52�, phone TYPE OF WELL/PUMP: NEW WELL ❑ _ WELLREPLACEMENT ❑ 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 Dia. of Well Casing ❑ Domestic/Private L7 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal e s Type of Grout T ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Instafled tty Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material flop 50'1 _ Depth Filler Material IBelow 50'J", j r- TYPE OF SEPTIC WORK: NEW INSTALLATION LL—REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s available within 200 feet.) ((00 Installation will serve: Residence-Le C ommercial Other I Number of.living units: —I-- Number of bedrooms '5 -�'i= ; Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 5 Ca act I p tY No. Compartments PKG. TREATMENT PLf.n Method of Disposal Distance'to nearest, e Well ZOO_ Fotndation -4 d _ Properly Line — LEACHING LINE ��; r?:-Length of lines Total length site FILTER BED , � c ar { ❑ Distance to rieare�t: Well� Foundation �L Property Line.___ _ SEEPAGE PITS F) '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. ' I Ir Home owner or licensed.agent's signature certifies the following: "I certify that in the performance of the Work f6-r--which this permit is issued, I shall not employ any person in such manner as to become su"je6t to workman's compensation laws o�Califorrpia."'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'Californ_ia." The applicant must call for all uired in ctions. Complete drawing on reverse side. Signed ` Title: Date: OR DEPARTMENT USE ONLY c/--��// Application Accepted by �' Date 7 < " 4" Area29 7 Pit or Grout Inspection by Date Final Inspection by f Date -� 4 Additional Comments: ❑ Stk 466-6761 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'N0. INFO CASH ..t-EH 13-24 1 REV.1/R 51 EH 1428