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. r - APPLICATION FOR PERMIT Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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 Address � YCity Lot Size L r �a QPM Owner's Name Zoe Address6C/�i � � Phone �Z Contractor � l! ss ..S 4�EF16�L 1�0._� A� �� Phan TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI N ❑ SYSTEM REPAIR ❑ �O..yyTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES - � DISPOSAL FLQ)2&4-PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation—/-Z' Dia. of Well Casing -:6-Domestic/Private Gravel Pack j "S4-Tracy Type of Casing A/c S&,A_16L Specifications �j f'1 Public 1-1Other 171 Delta Depth of Grout Seal /00�% Type of GroutU-.15/1 �-- I I Irrigation � _.Approx. Depth l I Eastern Surface Seal Installed by �\ Repair Work Done Ll "Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAMIADDITION i 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence T._ 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. ❑ 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby c6rtify 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 fallowing: "I certify that in the performance of the work for which this permit is issued, 1 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." The applic all r all quired in pections. Complete drawing on r v rse side. Signed XCA QZ 64 Title: Date: 7/d FOR DEPARTMENT USE ONLY Application Accepted by Len,SN Date Area IL Pit or Grout Inspection by Date Final Inspection by Additional Comments: >` l& / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ a eca 3-7104 Tracy 835-6385 Applicant(- Return all copies to: EnvironmentalnHe- th Permit/Services 1_60-11 E. Ha Ave., P.O. Box 2008, Stk., CA 95201 ?11I - f. no �tc�S7�C. 1 wteCrnife. Cv i INFO FEEAMOUNT DUE AMOUNT REMITTED GASB K 4 RECEIVED BY f DATE�y �P/ER�MjITNO. +.EH 13-24(REV.t i H 51 C47V EH 1MOW 426