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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 t (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 I Local Health District. . r Job Address y1.fD _ /a o' Jw �.� City Lot Size + PM I I Owner's Name < Address 6 Phone I Contractor U Address/.d Kazl L License No. (93 t'23 Phone 8120 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 Pack Domestic/Private Gravel Pack ❑ Tracy Type of Casing_i - r Specifications c)-:15S 'A VVF1 Public n Other F1 Delta Depth of Grout Seal rSL� f Type of Grout rrtF% I Irrigation —Approx; Depth l I Eastern Surface Seal Installed by _ (� Repair Work Done ❑ Type of Pump H.P. State Work bone_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence I Commercial— -Other Number;of living units: Number of bedrooms Character of soil to a depth of 3 feet er table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE ❑ No. & Length of line Total length/size I FILTER BED ❑ Distance t rest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS CI Distance oto nearest: Well Foundation Property Line DISPOSAL"PONDS ❑ - f I hereby certify that t 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must I for required inspections. C plat drawing on reverse side. s Signed X .`'�"'�t� Title: Date: FOR DEPARTMENT USE ONL Application Accepted by Dat �� Area �✓ j Pit or Grout Inspection Date Final Inspection by Date Additional Comments: h ❑ Stk 466-6781 ❑ Lodi 369- ❑ Manteca 823-7104 ❑ Tracy 6385 Cpu�re hf �C:C�eQw�G. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE {NFO AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT,'NO. a EH 121 Ir��.EV.1 IS 51 1J .� IQ EH 128 1, i