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ZX APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -y I: ;�vO t. .. r, k(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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 0 D Q ' e �� City -'`�"°� Lot Size ��C. " " PfiA Owner's Address Name LJI i ��y� - (', Phone _�•`7 Contractor's Name � [ `� �._ License No. V� ( ° 0 Phone IV ►f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ —PUMP INSTALLATION'";- � SYSTEM REPAIR"A OTHER. " DISTANCE TO IV_EARE5_T_:_SEPTIC TANK _ _SEWER LINES a 20Vt DISPOSkCFCD. ��.;PROP.-LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ElTracy Type of Casing_ Specifications t ❑ Public ❑ Other ❑ Delta f Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.i Depth ❑ Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump _ Mip., Z State Work Done e W Well Destruction El Well Diameter 4sealing Material Itop 501 Depth Eller,Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 ( available within 200 feet.) Installation will serve: Residence_'A•-Commercial_�=Other T— - - .- = -"-.•�-,�:e,,. -+�.,:..,�-.�,.,.,�._�„�,;,;�,r� " Number of living units: Number of bedrooms I i Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ # s I " Method of Disposal Distance to nearest: Well' Foundation `�Property Line ` LEACHING LINE ❑ No. & Length of lines Total length/size LLL FILTER BED ❑ Distance to nearest: Well;" Foundation fiProperty Line SEEPAGE PITS ❑ Depth I Size' " ' Number E ea - SUMPS E-1Distance to nearest: Weill' 'Foundation { "Property Line DISPOSAL PONDS ❑ is E hereby certify that I have prepared this application and thai 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." Contractors 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 applica�upl for all iquir i pections. Complete drawing on rev rse side. �dc " Signed Title: r Date: f "� 1 FOR DEPARTMENT USE ONLY / Application Accepted by y Date / �� 3� r�"' Areas - Pit or Grout Inspection by � Date Final Inspection by Date " 177 Additional Comments: ❑ Stk 456.5781 -" ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 - =• Applicant- Return all copies to: Environmentai Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK r'"• IFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO." + EH 13-24 4REV.101831 1 S` ov W EH 1428 �!