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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 TYEAR 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 5 TT AA +c City Lot Size PM Owner's Name ° GOILI ZR Address Phone Contractor[A )4kLA NAL CnL.J�Address s License No. a/ phone G5 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 f 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 El Domestic/Private 171Gravel Pack LJ Tracy' Type of Casing Specifications n I'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout—.—.—. ! I I Irrigation -_Approx. Depth ( 1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ti Sealing Material Itop 501 Depth .Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION LL-anTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) F Installation will serve: Residence Commercial! Other Number of living units: r Number of bedrooms Character of soil to a depth'of 3 feet: ht i�'1J Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property.Line C� LEACHING LINE'. E*--l1-o& Length of lines s Total length/size ` FILTER BED ❑ Distance to nearest: Well. Foundation ZY Property Line_..._._ -.- SEEPAGE PITS I iL+TY—ep—th Size u ber SUMPS ❑ Distance to nearest611 F un"ation PP Y ro ert Line t DISPOSAL PONDS El ' 1 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 DiMrict: - I 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws o alifornia ' The applicant s call r all equir ins ti omplete'drawing on reverse side. Signe y Tif1e:' - R �/' � Date,—,3< t ' -FOR DEPARTMENT USE ONLY Application Accepted by r r Date [ Area 6 Pit or Grout Inspection byT Date ��4 Final Inspection by �' rJ7. f Date` S n . Additional Comments: El 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 FEE INFO AMOUNT DUE AMOUNT REMITTEO CASH CK 9 RECEIVED BY DATE PERMIT NO. 3 C� +.EH 13-24 IREV. , ! 64" r/ . L �� EH 14-26 V V ..J f „ y�. k