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APPLICATION FOR PERMIT J 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 Ad9 /dress I ry re City Z446 4d2jLot Size-__tel- PM Owner's Name t ;LZVI&4e `�G o Address Phone + Contractor Pr` C Address fs r' License No.�j Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN X❑ j DESTRUCTION ❑ PUMP INSTALLATION ,SYSTEM REPAIR ❑ OTHER ❑ 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 Pa&- _ ,.r❑ Tracy Type of Casing Specifications f"1 Public HCl Other - n Delta "{ Depth of Grout Seal Type of Grout i I Irrigation Approx. Depth I Eastern SVace Seal,.installed by _ r Repair Work Done ❑ Type of Pump~ �?U ib H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material (top 50') Depth :Filler Material f Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I I' REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted it public sewer is 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 l SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well �° Foundation Property Line , 5 I LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line v� • SEEPAGE PITS i I Depth Size _ _ Number d SUMPS [1 Distance to nearest: well Foundation Property Line DISPOSAL PONDS ❑ .t 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 DoltricL 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 f certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call fDr all rewired inspectioC plete drawing on reverse side. / Signed Title: Date: FOR'DEPARTMI417T USE ONLY Application Accepted by " t�l Cn— Date t Area Pit or Grout Irispection by Date Final Inspection by Date Additional Comments: ❑ 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 AMOUNT DUE AMOUNT REMITTED I CK H RECEIVED BY DATE PERMIT'NO, INFO +.EH13-241REV.1/855 EH 14-28 L X211