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F {f ^4 =t APPLICATION FOR PERMIT A- SAN JOAQUIN LOCAL HEALTH DISTRICT 16011.E. HAZEL T ON AVE:,' STOCKTON, CA ' Telephone (209) 466-6781. # PERMIT EXPIRES i YEAR,FROM, DATE ISSUED ; t r (Complete in Triplicate) w 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'Sari 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. 1� R i i Job Address fv f city r Lot Size PM Owner's Name16 ZC t Address p Phone Y ( — J r Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT_ ❑ DESTRUCTION ❑ PUMP INSTALLATI ❑ SYSTEM REPA OTHER ❑ ` DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ` RICULTURE LL OTHER WELL jPLTS/•SUMPS F INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom' ❑ Mante Dia. of Well Excavation ' Dia. of Well Casing 1-1Domestic/Private ❑ Gravel Pack O Tr y T of Casing Specifications ❑ Public ❑ Other'' F Delta Depth f Grout Seal # Type of Grout ❑ Irrigation . Approz. Dept ❑ Eastern Surface al Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑r` Well Diam r Sealing Material {top 50'1 /", � ..th De . P Filler Material (Below 50'1 TYPE OF SEPTIC WORK:' NEW INSTALLATION ❑ . REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ., available within'200-feetL) Installation will serve: Re 'dence Commercial Other + Number of living units:aQ� Number of bedrooms Character of soil to a depth of 3 feet: " Water,table depth SEPTIC TANK ❑ Type/ ; YP g; Capacity a # 'No: Compartments � PKG. TREATMENT PLT. ❑ / Method of Disposal ai Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance�to nearest: Well '` Foundation ti Property Line k SEEPAGE PITS ❑ Depth Size Number ' ,.r i SUMPS CI Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this Iapplication 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 Califomia. 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." T licant mu t call for all required inspectio s. omplete drawing on reverse side.h` Signed Title: r Dater FOR DEPARTMENT USE ONLY rs Application Accepted by .DateT�J �"' Area Pit or Grout Inspection by Date Final Inspection by Date fGZ - Additional Comments: ;0n W/o W D !� k ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104' ❑ Tracy 835-aw Applicant-.Return all copies to: Environmental Heafth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEEr -h ; INFO AMOUNT DUE I AMOUNT REMITTED f C RECEIVED BY DATE PERMIT"NO. + EH 13-24{REV.1/857 EH 14-2e ` a F . 00 i