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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,, STOCKTON, CA ] Telephone (209) 466-6781 PERMIT EXPIRES !'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, z /�] Job Address �C/gazu. Wt �r'� Il.�lz Ci Lot Siz PM Owner's Na Address Phone r ! r Sia Conlrac o Address r License No. Zd Z Phone TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F 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 c�` F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ( ,V I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by �N Repair Work Done ❑ Type of Pump H'P --State Work-Done (\t Well Destruction L] Well Diameter Sealing Material (top 50') DepthMaterial Ieelow 50'1 TYPE OF SEPTIC WORK: -NEW INSTALLATION EP - ADDITIO DESTRUCTION I I (No septic system,permitted if public sewer is 1 -a-..�� =--J�`" '�� ' T ,�. available within 200'feet.] Installation will serve: Residence Commercial Other11�'`.- / Number of living units: r Number. dr m�— Character of soil to a depth of 3 feet: ��- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ -- - -- — - -b -- - Method of Disposal ✓ Distance to nearest: Well Foundation Property Line LEACHING LINE 0' r K No. & Length,of lines TPtal length/size FILTER BED ❑ Distance to nearest: :. Well S�Q Foundation_`_� Property Line_-- � SEEPAGE PITS i I Depth 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 Di"strict. 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: "1 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 ifomia." The applicant u call for I r uire inspections. Complete drawing on rover s�e Signed X }� ..T.itle: Date: FOR DEPARTMENT USE ONLY d Application Accepted by Data 1�]( Area C� Pit or�GroutAnspection by Date Final Inspection by a (M\�r�� Date ditd tonal Comments: ❑ Stk. 466-6781 ❑ Lodi• 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Serviced 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 FEE INFO AMOUNT DU AMOUNT REMITTED CK IS RECEIVED BY ...DATE GG PERMIT-N O. t.EH13-24(REV.I IK5) EH 14-29 11 `