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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 NJ 0 km�oL� /COI p�_ d� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N/ v1R+4 / � � (Complete in Triplicate) Application is hereby made to the San J aquin 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 rLJ `S>/ City Lot Size PM Owner's NamR,ZW4A-1V4g%WAddress ��r �y s� Phone Contractorv /_ AddressLicense No.y Phone \ TYPE OF WELL/PUMP: NEW WELL ❑ WELL R LACEMENT ❑ DESTRUCTION LJ PUMP PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU WELL OTHER WELL PITS/SUMPS _ INTENDED USE _TYPE OF WELL P M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grav ack ❑ Tracy Type of Casing Specifications nPublic ther ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _..Approx. Depth 13 Eastern Surface Seal installed by Repair Wor on ❑ Type of Pump H.P. State Work Done Well truction CO Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501OC r TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is �o 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ED 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 applican must c II for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FPARENT USE ONLY SI Application Accepted by aCA46,_ .� Cir., Date I� 1 Area Pit or Grout Inspection by ate Final Inspection by ,l Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-361 ❑ Manteca 823-7104 NdTracy 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 REMITTED l,CK RECEIVED BY DATE PERMIT'NO. + E324 4-2f REV.1 51 � 0 O (7,V J VEH 1 / C) (�-!g2n