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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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, Job Address cit;Z-4, Lot Size PM Owner's Na Address Phone Contrac `I Address,4,"_ _Z�Zen?'l icense No� 2.2 6 Phona� J !06 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CJ 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications — f` Public FI Other Cl Delta Depth of Grout Seal Type of Grout t I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.-P. ' "-State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50'1 Depth 'ter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] RFPAI ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: _/_ Number of b Brooms Character of soil to a depth of 3 feet: Water table depth (1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 s - Method of Disposal Distance to nearest: _Well- Foundation Property Line LEACHING LINE >1/ No. & Length of lines Z T— Total length/size FILTER BED ❑ Distance to nearest: Well. Foundation Property Line N:5-- SEEPAGE PITS 11 Depth f� —Size p� Number SUMPS >< Distance to nearest` Well 160' 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 m t call f re fired inspections. Complete drawing on reversed side Signed X Title: V. Date FOR EPARTMENT USE ONLY g Applicati Accepted by� f _ Date Area 'Pit ut-ffispect+Eon by ate-- V_';;'!P1Final inspection by Additional Comments: LI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 RECEIVED BY DATE �/ PERM`IIT'NO./] +.EH13-24WEV.t/H51 ! Oi Q4'7 ��y �p EH 14-29 ��.��^^^ ��ffifff r 4 _ �