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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE, STOCKTON, CA F.' Telephone (209) 466-6781 f PERMIT EXPIRES i 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 F Local Health District., 111 Job Address 2; �� a ��( T je (r�� City Ze,l�j 1�1% 1-ot Size ZiW JC_.,/3-0 PM ,0000w z� Owner's Name �' Address �� Phone �� Contractor's Name% 1009 ''/c'.IS4f -L'&t414 License No. '' J — Phone 916 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ kP DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD, PROP. LINE r 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 C1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal + P Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump, H.P. State Work Done C 1 Well Destruction ❑ Well Diameter0'). Sealing Material (tap 5C li Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I. available within 200 feet.) k Installation will serve: Residence V---Commercial_ Other I J'I At(' Number of living units:-0— Number of bedrooms Character of soil to a depth of 3 feet: ' y" Water table depth SEPTIC TANK Type/Mfg Capacity—'Z 0 0 No. Compartments �— PKG. TREATMENT PLT. 0 Method of.Disposal .t Distance to nearest: Well_/f/22 Foundation /dO Property Line LEACHING LINE :1 7I4o. & Length of lines r D Total ength/size d FILTER BED ❑ Distance to nearest: Well—Ai,, Foundation—,V If Pro I` perry Line_js SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 (" certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa Il , tion laws of California." The applicant calf for all required inspecti ns. Complete drawing on reverse side. Signed Title: .. Date: n FOR DEPAR NT USE ONLY i Application Accepted by Date Area Z-- Pit or Grout Inspection by Dae Final Inspection by Date Additional Comments: zs� ❑ Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823- X04 ❑ Tracy 835-6385 E Applicant- Return all copies to: Environmental Health Permit/Serv(ces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. f EH 1324(REV.10183) t Irl 1 1 EH 1426 �J 1 l Z(3 _ l