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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :r (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 Sari Joaquin Local Health District. Job Address / ,City JLot SizePM Owner's Name ,Ze2 l Address -- -y�� Phone Contractor ,�1, , `vGG�r2 _Ad dress J�U. f�1� i�t��Q License No.a�/� c� �Phone 1 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑.Eastern Surface Seal Installed by Repair Work Done _❑ Type of Pump H.P. ' ti State Work Done Well De) struction d Well Diameter ' rxSealing•Material (top-50'),' —" r J Depth _ Filler Material (Below 501 _1 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.ADDITION ❑ DESTRUCTION C1 (No'septic system-permitted if public sewer is i I 11 1 1 available within 200-feet-) Installation will serve:* Residence Commercial Other r- Number of,living unit:{ Number of bedrooms Character of,soil to a"depth of 3 feet: kJ trl /�z77A Water table`depth SEPTIC iTANK _ 1 { �1 Type/Mfg f ��'"�1=j` �" �� capacity i � No. CoGortlpartments PKG. TREATMENY PLT. ❑ ' ✓ �� MethodofDisposal t Distance o nearest; Well Foundation �G t Property Line" �c3 F7 r LEACHING LINE F ❑�No. & Length of lines Total {ength/size 3 FILTER ED ��' Distance to nearest:.,,,,. Well. ' 7_ .Foundations i 3v X7 � Prop rty Line -��% LA SEEPAGE PITS rpt ❑ Depth Size 1 Number IO SUMPS(. r:? ❑ Distance to nearest: Well Foundation - i Property Line 1 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. f 1 1 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 intheperformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call fo ll required inspections_Complete drawing on reverse_side, Signed X Title: -: "3� Dater FOR DEPARTMENT USE ONLY 2 j Application Accepted by )?4114 4ae2 Date �✓ Area Pit or Grout[inspection by Date Final Inspection by ` Additional Comments: I ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 4 EH 13-24[REV.If e 5t EH 14-28 L�