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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 I 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 Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. a Job Address 7� (� r `� r'� City ` 4G1 Lot Size_ PM Owner's Name Y Li Z , I.T Address Phone Contractor G. 't Address 104zl, lob 1 f License No. Phone" s �• s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ r tt DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP.'LINE i {. ! FOUNDATION AGRICULTURE WELL , OTHER WELL PITSLSUMPS ' f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i [a Domestic/Private ❑ Gravel Pack r ❑ Tracy Type of Casing r Specifications t ('l Public �` j 1-1 Other (7 Delta Depth of Grout Seal Tipe of Grout I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done{ i t Well Destruction ❑ Well Diameter Sealing Material (top 501 t •" Depth !"x Filler Material (Below 50') 1 TYPE OF SEPTIC WORK; NEW INSTA�TION REPAIRIADDITION l I' DESTRUCTION ( I (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' &K—Type/Mfg C r;, enc► «- Capacity ?' No. Compartments I PKG. TREATMENT'PLT. ❑ .. "� of ,r 5.. Method of Disposal Distance to nearest: Well Foundation -,— Property Line _ t { LEACH.ING LINE No,`& Length of lines _ � Tota! length/size ` FILTER BED i' ❑" 'Distance to nearest: Well ` + :Foundation Property Line SEEPAdE_JP-IT.S_, k I Depth Size Number l_ — s SUMPS I .1""��istance to nearest: Well', Foundation (�1 Property Line j DISPOSAL PONDS ❑ a hereby certify that I have prepared this application and that the workl�will be done in accordance with San Joaquin county ordinances, state laws, and I rules and,regulations of the San Joaquin Local Healffi.-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 wdrkmin's compensation laws of California." Contractors hiring or sub-contracting signature certifies.the following: "I certify that in the performancof:the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws-nf Cafifornia."=i- 4, r The applicant must ca for all r uire I inspections. Complete cla ing on reverse side. ;. t p Signed X .Title:" Date: _ w FOR DEPARTMENT USE ONLY Application Accepted by Data z- �� Area l I 3 Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE INFO AMOUNT DUE t AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. 1 1 +.EH 13-24(REV._t i n 5) ��r 1`9 i