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i i APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL. HEALTH DISTRICT P1601 E. HAZEL T ON AVE., STOCKTON, CA ePCr c �/ 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. Job Address��T/1��1r� irja[ P7v CityX[ZZ — Lot Size PM F, Owner's Nam e4 XI" �11 147601711 Address yr/f r�4rir�r;L se��D, f�hone - - Contractor ZZG Address0` /_t { License No.3221:_ d Phonek92 66 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ LJ PUMP INSTALLATION ❑ SYSTEM REPAIR)4[ OTHER ❑ ' ��^^ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION s .AGRICULTURE WELL - OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -?(Domestic/Private 1-1 Gravel Pack ❑ Tracy Type of Casing Specifications F, ('1 Public F1 Other f71 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern S ce Seal Installed by A _ Repair Work Done Type of Pump s H.P. State Work Done ! Well Destruction O Well Diameter Sealing Material (top 501 II Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADD1TION { I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.] I Installation will serve: Residence_ Commercial Other I'f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments h PKG. TREATMENT PLT.❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line F F!1 LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F. SEEPAGE PITS I I Depth Size Number ' SUMPS Ll Distance to nearest: Well Foundation '' Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done,in accordance with San Joaquin count ordinances, state laws. and R 11 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, l shall not employ any person in such manner as to become subjecttoworkman's compensation laws of California."Contractor's hiring or sub-contracting signature �i 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 compe a- tion laws of California." The ap call for all require pact; s: Co ete drawing on reverse side. ff Signed X Title; Date; _ ! ' FOR DEPARTMENT USE ONLY Application Accepted by _ tI`E'1v ' _ Date �� Area Pit or Grout Inspection 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 20D9, Stk., CA 95201 _ AMOUNT DUE AMOUNT REMITTED CASH VAI rr�(�Irf No, FEE INFO GK RECEIVED by _EH M241REv.i/asr i EH$428r_