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�I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . Job Address + City Lot Size pM Owner's Name Address lczeG42 ii ! Phone 1 ContsWa ract Address� 7 � License �E Phone -� i TYPE OF WELL/,PUMP: Vii, 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout ❑ Irrigation LApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ;r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public s11 ewer is available within 200 feet.) Installation will serve: Residence_ Commercial= Other Number of living units: Number rof"bedrooms Character of soil to a depth of 3 feet: ' r, i Water table depth SEPTIC TRK ' Type/Mfg Capacity "� No. Compartments PKG. TREATMENT-PLT. ❑ �I ti I. } Method of Disposal Distance to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line rl I SEEPAGE PITS XDepth I Size Number SUMPS ❑ 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, I shall employ persons subject to workman's compensa- tion laws of California." it The applicant ust call for all re uir inspe ions. Complete drawing on reverse side. igned Title: Date: i FOR DEPARTMENT USE ONLY -10- Application Accepted by Date r> 1 Area 1 f Pit or Grout Inspection Date Final Inspection by Date—all �. Additional Comments: � i i ❑ Stk 466-6761 ❑ Lodi!I 369-3621 ❑ Manteca .623-7104 ❑ Wary' 83 Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH EH 14- + EH 14241REV,iia 51 IIjWilII 5 ' Qo �Z 24 Ii �( a �• �^gyp ` . i, I J.