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ZIP APPLICATION FOR PERMIT ,.� SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA N O `Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. y t. {Complete in Triplicate) aJ 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 c Lot Size PM c Owner's—Name n I9—✓L!(_A_AN ti Address /y / �_. e Phone ` w Yt _ ;� onfractor I C-ox Address TYPE OF WELL/PUMP: �I NEW WELL ❑ WELL REPLACEMENT Ely "bE$TRUCTIONX -- PUMP 1NSTALLATION1I] SYSTEM REPAIR'jQ - R LJ n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P i' FOUNDATION AGRICULTURE WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREACTION SPECIFICATIONS l ❑ Industrial# ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic)Private '❑ Gravel Pack racy Type of Casing ISpecifications ) ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i �I ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by ^� \it I Repair Work�Don Type of Pump H.P. � State'Work Done ° est ton ❑ Well Diameter Sealing Material (top 50'1 M + DepthFillerMaterial (Below 50') N. I YPEzOF;SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 fe0) installation'will serve: Residence_ Commercial_ Other Number of living units: :+f Number of bedrooms Character of soil to a depth of 3 feet: _ % ter table de th SEPTIC TANK ❑ 4pe/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I� Method of Disposal 1. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines To ail ngth/size FILTER BED ❑. Distance to nearest: Weil Found ion Property Line SEEPAGE PITS 1i depth Size Number � SUMPS El Distance to nearest: - Well Foundation Property'Line's: DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county or�6iih54 ces, state laws, Ad rules and regulations of the Sa� 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 shlill 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 certifylthat in the performance of the wprk for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call required inspections. Complete drawing on reverse side. Signed I Title: bate: ft / f0 DEPARTMENT USEDY, Application Accepted by F Q:. + Pit or Grout Inspection byIF Date Final Inspection by Date Additional Comments: li ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. JI. _ + EH13-24(REV,i'/ 5) to-t7(� 0 EH 1448