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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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/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. CL �J Job AddressAIZ Cit '�O X `�'S Lot Size 2 � 'PM Owner's Name dz�e Address 2lPZ? /[sem Phone 'Contractor +r'4ddress License o. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAI OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WI=LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well..Casing Cl Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i lfrigation A x. Depth I 1 Eastern Surface Seal installed by Repair Work Done [. a 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 I I REPAIR/ADDITION rl DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial_ Other Number of living units: . . I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth g C, 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 I Z Z� g Total length/size 2t7- FILTER BED ❑ Distance to nearest: Well Foundation /01 Property Line fir- r SEEPAGE PITS IK Depth J� t� Size ryr 3k ii Number ! SUMPS ❑ Distance to nearest: Well M Foundation 10 ! Property Line S 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 Di$trict. 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed & Title: Date: Z� q FOR DEPARTMENT USE ONLY �J— Application Accepted by Date /11 ''ZrcS"� Area 12— r Grout Inspection by ate ''� Final Inspection by.fid �t'7 Date (Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. aEH13-241REV.1/65) 0 06 C4 p��/� EH 14-26 i!