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F 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. ZE tTJ� city.Address kLot Size PM M - Owner's Name C/T/�c L �l 16AZU-0/V Address 0_(!�� 4_ MordPhone 13 Contractor �E�f Address License No. Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ fi PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOU AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL EM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout a Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material {top 50') 5 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted ff public sewer is available within 2DD feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number 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 Foundation Property Line \� LEACHING LINE ❑ No. 8k Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f al�ired ctions. Complete drawing on reverse side. Signed Title: Date: 0-:16 � DEPART NT USE ONLY �r 7 / (J r Application ccepted by Date l� � Area la',, k Pit or Grout Inspection by Date Final Inspection by1 Date 11 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 VV Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St ., CA 9520FEE1 INFO. AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO.' p ' 1,:i�W EH 13-24IREV.ties} o� �` 0t 6 V