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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �d �� 1601 E. HAZE i 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / a.� � Ae S TO�t/ City s/ 4A Lot Size f M Job Address _. . Owner's Name &11 LSVAZ— Address Phone Contractor L�1 y� 4/00 Address 7AA L License No. a 76 Phone 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 WELLPROBEM LAREA CONSTRUCTION SPECIFICATIONS '❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack �4 r❑ Tracy i i Type of CasingSpecifications I-I Public 1-1 Other C-1Delta ;.y. Depth of Grout Seal t Type of Grout I I Irrigation _..Appro"eDepth—t"I"Eastern' Surface-Seal-Installed-by--< Repair Work Done ElType of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50T), Depth Filler Material (Below 50') <7�� 3 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION l I DE R CTION (No s tic system permitted if public sewer is .� avai le within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: &-f- 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. ❑ It Method of Disposal Distance;to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distancek'to nearest: Well Foundation Property Line SEEPAGE PITS I'I Depth i' Size ' _ Number r t SUMPS L7 Distance`to nearest::- -We11'"'"'""`—�11`pund&On 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 taws 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 must call for all required inspections, Complete drawing on rerverse side. Signed X a Title: Date: i I �DFPA�RTMENT�USE ONLY q Application Accepted by Date Area 2��Pit or Grout Inspection by Date Final Inspection by Date 8 Additional Comments: No j< ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 83E(6385 Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH �.EH1324iREV.t/K51 5 ,� F, l EH 14-215 ..