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APPLICATION FOR PERMIT SAN JOAQU€N LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 Z 1Wity t Size PM Owner's Name Address -Ztq— Phone Jr Contractor 711e, Z4 VI /s, No,/31 Phone� v TYPE OF WELL/PUMP: NEW WELL fl 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ['1 Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done G Well Destruction ❑ Weil Diameter Sealing Material [top 501 Depth Filler Material (Belo 'I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR ADDITION IV 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 bedrooms Character of soil to a depth of 3 feet: Wates_table depth SEPTIC TANK 0 Type/Mfg 70 Capacity No. Compartments 77 PKG. TREATMENT PLT. ❑ Method Disposal (13 Distance to nearest: Well , FoundationIr- Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel� - 'Foundation Property Line I SEEPAGE PITS i I Depth 9 1 VA LJW, umber MP L� Distance to nearest) Well oundation Property Line U ISP05AL 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 Ia s, and rules and regulations of the San Joaquin Local Health Dstrict. 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 taws of California." The applicant mk4st call for all req d 'nspections. Complep7drawing on r rs side. Signed X Title: '�- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date +E Area / 2— Pit 2- Pit or Grout Inspection by Date— Final Inspection b ` Date 31 Additional Comments? Cil { "� `-^1� g(JJ 5LS) ❑ Stk 466-6781 z ❑ Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13-24 iREV.1 i n sl —7O EH 14.26 1