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APPLICATION FOR PERMIT µ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j 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 Address �• it. el n City �K A"'• Lot Size b x f I PM Owner's Name ZZ0y0Lk40704!7;Z Address �l - s"fGr Phone Contractor LI' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 i ❑ Domestic/Private 1-1GravelPack ❑Tracy Type of Casing Specifications r- FI Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout W I I Irrigation _-Approx. Depth i I Eastern Surface Seel Installed by t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 4 Y Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is favailable within 200 feet.) Installation will serve:—Residence—! Commercial— Other Number of living units: Number of bedrooms l I Character of soil to a depth of 3 feet Water table depth t SEPTIC TANK ❑ Typd/Mfg '`Capacity No. Compartments (� i PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance!to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number `{ SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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, I shall employ persons subject to workman's compensa- tion laws of California." r The applicant must call for all required nspections. Complete drawing on r verse side. Signed X Title: _ Date: 9 *� k FOR DEPARTMENT USE ONLY M a y Application Accepted by Date - I Area ` Pit or Grout Inspection by Data—,Final Inspection by 1 r • L Date A ditional Comments: l� 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Wanteca 823 7104 ❑ Tracy 835-6385 . pplicant - 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 PERMITNO. INFO �7 + EH 13-24 MEV,tiH5) l .� �U`, k— 4) -5 + (, EH 14-26 V 111 -+ fir