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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IcX.71 .` .,F OSS 11-e-0-�_ V4, (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. �� Job Address �• �� - t4L City tot Size PM Owner's Name Address LEA" *ZC1t4ifA4A6L,1 + Phone Contractor's Name Ve— License Nor Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t 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 C1 Manteca Dia. of Well Excavation Dia. of Well Casing -� X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N I� a ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r: ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by _ Repair Work Done i' Type of Pump H.P. I I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 A Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 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 1` Distance to nearest: I Well Foundation Property Line LEACHING LINE„ ❑ No. & Length of liries Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation Property Line r � SEEPAGE PITS ❑ Depth Size Number , SUMPS ❑ Distance to nearest: Well Foundation Property Line I : 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 f_ rules and regulations of the San Joaquin Local Health District. IF, C. Home owner or licensed agent's signature certifies the fallowing: "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 m t`c for quired inspections. Complete drawing on rev side. Signed Title:~moo Date: FOR DEPAR ENT USE ONLY Application Accepted by Date Pit or Grout Inspection by IVIADate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. INFO H + EH 1324(REV.10183) `�� \ .�7r •�1/ ��9 EH 14-28 ��1