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APPLICATION FOR PERMIT3�/ C SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,'STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address .: City a//` "Lot Size PM Owner's Name Zsc d'- Address _ �®Vl/i.�" = Phone f a Contractor S Address �J� a License No. e? Phone TYPE•OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA EST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _1 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS `T j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing >Z,�estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications + ❑ Pulalic ❑ Other - ❑ Delta Depth of Grout Seal Type of Grout I El Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by RepairI Work Done 0 Type of Pump H.P._ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 � ?� Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is I available within 200 feet.) III Instillation will ser,e: Residence_ Commercial Other i Number of living units: Number of bedrooms rn Character of soil to!a depth of 3 feet: Water table depth LI, f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. ❑ '33 Method of Disposal -� Distance to nearest: Well Foundation i Property Line .; I, in E LEACIi1NG LI E No & Length lines I I Total length/size FILTERof BED 11=nce_�o1 .nearest: Well Found Property Line SEEPAGE PITS `Depth Size ` Number SUMPS `Dist..Ihbe to nearest: Well Foundation Property Line (� DISPOSAL POI5 n I I hereby certify-that I ave''"pre�ared'-this application and that the work will be done in accordancelwith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or)i6ensad 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 pergon in auch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follo`wingl"1 certiiN that in the pe or-ra�`mance`ofThework for wtirch this permif:is issuea,,-tshall employ persons subject to workman's compensa- tion laws of Ca lornial." 1 The applica u F r I req u' ions. Complete drawing on reverse side. Signed' Title: / �N �� Date: J��Z/'I�Z9 i aA;_ DEPARTMENT USE ONLY _P7 Application Accepted by // Date 7 Area I Pit or Grout Inspectio,i by Date " Final Inspection by Additional Comments. ❑ Stk 4661 10 Lodi 369-3621 ElManteca 823-7104 ❑ Tracy 835-6385 j Appliont 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'NO. INFO CAiSH + EH 13-24(REV.1/8 5) 35- 00 �37� -EH 14>2a —