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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 Heakh 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 rr Local Health District. �, lS' �"c ZI 3 Lv rzk- z U 7 / z� C.v .o Job Address City Lot Size 7 PM �`'�e�✓ Owner's Name V �F l- �y AVO Z—Address S/� Phone 5"j r ✓ 3 ` Contractor Address,. License No. Phone TYPE OF WELL/PUMP: NEW WELL O 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 O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications -� El Public r y„. ❑ Other 5 1-1 Delta Depth of Grout Seal Type of Grout LJ 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-50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is /` available within 200 feet.) Installation will serve: Residence! Commercial_ Other I Number of living units: Number of bedrooms _- Character of soil to a depth of 3 feet: ! Water table depth SEPTIC TANK Type/Mfg d0 (Capacityfb No. Compartments PKG:TREATMENT PLT. ❑ / Me#hod of Disposal Distance to nearest:. .. Well Foundation Property Line LEACHING LINE Plo. & Length of lines ”' ?r =� Tgra! length/size— FILTER �, - f, FILTER BED ❑ Distance to nearest: Weil eundatior C - Property Line SEEPAGE PITSUepth.1 •. r. +, _ Number . --f SUMPS Distance to nearast:; . ;iNeIIZ' t roundation _e Property Line: DISPOSALP( ❑ 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 subcontracting signature certifies the following:"I certify that in the,pe_rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ,* \ H The appli t must call for all required inspect' ns. Complete drawing on reverse side. Signed r :2Title: Date: f FOR DEPARTMENT USE ONLY Application Accepted by Date /7r4:�Area Pit or Grout.Inspection by i'At Date Final Inspection by pate Additional Comments: ❑ Stk 466-6781 ❑ Lodi'-"369-3621 ' ❑ Manteca 823-7104 Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. azeltan Ave., P.O. Box 2009, Stk., CA 95201 kz INFO AMOUNT DUE,_ - AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. + EH13-24(REV.1/9 5) --7A --7Q ©o } ` 1� g� Fr6�-� EH 1426 L rt i