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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA { Telephone {2091 466-6781 p PERMIT EXPIRES TYEAR FROM DATE ISSUED II (Complete in Triplicate) i 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 A ;1 Job Address s City r K J C.ILbt►Size �FM� Owner's Name ddress x- 1 v -C� o1e l_J a G-.DZ.ZZ Phone Contractor `1<� � f.0 �'�''�dress - L ense No, TYPE OF WELL/PUMP: ; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ •t y 0, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � I� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS' INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIENS--"',t 0 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation 4 s o<;J)ia. of Well Casing el D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ----Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t I DESTRUCTION (No septic system permitted if public sewer is u available within 200 feet.) 1 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. ❑ 11 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑. Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS E Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 D&rict. J 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: "1 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 applica t t II for al fired inspections. Complete drawing on reverse fide. Li Signed X _ Zukm� Title: Date: / o_r/- , FOR DEPARTMENT USE ONLY J Application Accepted by Data ur!`f Area + Pit or Grout inspectionb Date Final Inspection by Date Additional Comments Pr41 lgel�:71�1 " l0�zo s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2005, Silk., CA 95201 Ali ' it FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY DATE PERMIT"NO. INFO CASH +.EH 13-241REY.1/H51 �� S l,J6 EH 14-26