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i - APPLICATION FOR PERMIT ZC SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. l Job Address vti/ , Som 13kin. City Lot Size PM Owner's Name 0 r `-'L—, Address Phone Contractor (ALT BSINV .e- W& Address License No.�o gag Phone 3 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C] 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout _I 1 Irrigation _..Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well (Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t 3YRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence commercial— Other �f t /+z L✓ �GV Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1' / + Water table depth SEPTIC TANK fl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Aler& Length of lines Total length/size FILTER BEDnce to nearest- Well -Foundation Property Line_._ 7 r, Dista _ 'PV 6 C vj KtE R . v SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ J 0 X �1-0 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 c`e ies the following: "I ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion is California." The applicant call fo �Iejqui dins amplete drawing on reverse si ertfTitle: Date: �r FOR DEPARTMENT USE ONLY Application Accepted by Date Area _.^._ Pit or Grout Inspecti Date �7 Final Inspection by. ! rI /� Date 'zCl^Td Additional Comments: f 7�+ 7 �� fD i►�7✓�aa d u k,prl ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑Man ecatM a23-7104 ❑ Tracy 835 5 .��,,o(,�zQ �„ c Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 1/ INFO FEE AMOUNT DUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERM_I^T'�`NNO.. + EH 13-24(REV.i 5) EH 14-26 / (�