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' _ a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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/of 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 C Lot Size PM Owner's Name V: a4FZ, Address Phone Contractor_ � `{+"'�� Address 920Lw S' -w-0 License No.21D e3C> Phone T 6��' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANC TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT ELL PITS/SUMPS _ INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPE ONS ❑ Industrial ❑ Open B ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gra Pack ❑ Tracy Type of Casing 5pecr" ons I Public fl Oth Cl Delta Depth of Grout Seal Type of Grout I i Irrigation ---Approx. Depth i I Eastern Surface Seal Installed by _ + Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'f Depth " ' Filler,Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION o septic system permitted if public sewer is ailable 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t 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 i SUMPS ❑ Distance to nearest: Well foundation Property Line 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 Di1trict. 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'compeppation laws of California." Contractors 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 C r The applicant t ail required inspections. Complete drawing on reverse side. Signed X Title: � Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area , i Pit or Grout Inspectio y Date Final Inspection by I Date 9 Additional Comments: �' 7 Fc L k L ��b 0 L ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 YD Tracy 835-6385 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241FEE L INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. INt +.EH 13-24(REV.r/n 5) 6 -2 re f EH 14-2e `