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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 (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 ann�Jooaq�uiin- Local Health District. �E1�c 14I 9'� ? " "- 6_!a /,4c Jab Address �t�7'✓�y9t�L- �-�- fid/ 60 -2-1. City��e/UO"7 Lot Sir Pr'A �2 - _� Owner's NameCA� Zeoe.t2(W Address 3' O Z �A.Jl+4'� ^ Gr� Phone 3,C1 r- Contractor �y �.r.>( Address ��+ r� r�/aC'.��L�G� License No.30 577 Phone �6s"'j� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 14--REPAIR/ADDITION f I DESTRUCTION t 1 (No septic system permitted it public sewer is available within 200 feet.) ' Installation will serve: Residence i!< Commercial_ Other E Number of living units: ( Number oj bedrooms 3 Character of soil to a depth of 3 feet: LOfin Water table depth /p t SEPTIC TANK 6f' Type/Mfgo -b a Capacity OG No. Compartments Z PKG. TREATMENT PLT. El �Iltilgi" C. zu Method of�Disposal Distance to nearest: Well Foundation16/ Property Line LEACHING LINE R4 `No. S Length of lines .? O r Total length/size oZ 7O FILTER BED ❑ Distance to nearest: Well Foundation 30 r Property Line / SEEPAGE PITS I I Depth Size _ Number SUMPS U Distance to nearest: Well Foundation 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant all for.all/squired inspections. Complete drawing on reverse side. p Signed �f�JpJ��( Title: C0W'1t'# Date: C � O � 7 FOR DEPARTMENT USE ONLY Application Accepted by "'� y'�'_ Data ` f1O Area Pit or Grout Inspection by Date Final Inspection by- / Data 4 Additional Comments: 41.1, i f [ i ❑ Stk 466-6781 O Lodi 369-3621 Manteca 8237104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED. RECEIVED BY DATE PERMIT'NO. INFO a I� �i f�' S EH 13-7I(REV.I/x51 ��D ��/ A�/rC/ZJ 72P EH 14]9