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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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.7QL Job Address Z£ 5 E Kyezaz City Lot Size PM Owner's Name kA.El N4 �e — Address Z$ZS 'v`�G.t+re Phone �l Contractor AddressZS iF License No. fir'� Phone �°�7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X `,��p- n 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 I'] Public H Other C) Delta Depth of Grout Seat Type of Grout I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Bone 13 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50'1 N Depth Filler Material (Below 501 TY E OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) ,. Installation will se esidence_ Commercial __ Other rf t Number of living units: ber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Founda Property Line LEACHING LINE ❑ No. & Length of lines Total lengt FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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 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 Wst call for all required inspections. Complete drawing on reverse side. _ h� / Signed X `-714 � Title: r "`,Ct.[� � Date: V 1 FORD RTME T USE ONLY ��j Q Application Accepted by Date !7 " / Area ✓ �� Pit or Grout Inspection by Datet Final Inspection b C.Y . Date Additional Comments: S , ❑ Stk 466-6781 ❑ Lodi 369- 21 anteca 82V104 ❑ Tracy 835%385 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 CK RECEIVED BY DATE PERMIT'No. ♦ EH 13-241REV.iiNsl 3S~1 3,5110 ftp