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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 X:Zj�y� IZF /�� „._d/7/� City _02e Lot Size 0Z }C PM Owner's Name KZ -'' Address -Ceg/'1f= Phone .77 _J Contractor's Name /r&ooV,0C ff �,1'�'iLPS License No. __'7 .3 YJ Phone 1-1rC D U1i 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 oQ ❑ Domestic/Private ❑ Gravel-Pa—ck 0-Tracy"- Type of Casing Specifications Pj ❑ Public ❑ Other C1 Delta Depth of Grout Seat Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction— ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is available within 200 feet.) ID Installation will serve: ,.RR_;.' sidence Y Commercial_ Other Number of GWing unts: //L Number of bedrooms Character of soil to a depth-of 3 feet: C 14 . , . Water table depth CQ SEPTIC TANK E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 71 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines / rf7 Total length/size FILTER BED ❑ Distance,to nearest: Well 21--1 Foundation Property Line .16 / SEEPAGE PITS __ Size--- - �� Number SUMPS ❑ Distance to nearest: Well 4dt� Foundation /Lt[1-! 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 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." The applicant call for all required'nsctio s. Complete drawing on reverse std Signed Title: SP _ Date: f FOR DEPARTMENT USE ONLY L ,r Application Accepted by Date r Area 0/ Pi or Grout Inspection by ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all ebpids to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO JJAMOUNT DUE AMOUNT REMITTED CK 4CASH RECEIVED BY DATE PERMiT'�NO. + EH 13-24 1REV.14/831 EH 1426