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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Joaquin Local Health District. c^ �/ y�. Job Address �� fi ��l�"�EC 421-19 City m#�'JZZC14 Lot Size J 19-r- PM Owner's Name)W)%U7W14 COMV- ' Ad-dress _ _S/�'n�C— Phone �77 `0 Z?L 1 J tyre H W1 i Contractor,� E Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,/ FOUNDATION AGRICUL WELL OTHER WELL /SUMPS _ INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications r-1 Public n Ot n Delta Depth of Grout Seal Type of Grout I Irrigation Approx. Depth 1 1 Eastern Surface Seal Ins ed by Repair Work Don Type of Pump H.P. State Work Done_ r Well Destr n ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION^ REPAIR/ADDITION 1 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: __L�_Number of bedrooms ---� Character of soil to a depth of 3 feet: Water table depth Cj SEPTIC TANK X Type/Mfg Pd-L Capacity 3 Do No. Compartments ^� PKG. TREATMENT PLT. ❑ Method of Disposal ,�y Distance to nearest: Well Foundation Property Line LEACHING LINE �( No. & Length of fines /oo _ Total length/size Q � FILTER BED ❑ Distance to nearest: Well Foundation r Property Line F SEEPAGE PITS l I Depth Size Number SUMPS 0 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. �y= 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 F employ any person in such manner as to become subject to workman's compensation laws of California."..Contractors 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." The applicant r4st call for all re d inspections. Complete drawing on reverse side. 9 r -�� Signed X_ '' Title: Date: _3& .4 OR DEPARTMENT USE ONLY (I 1 Application Accepted by Date v f�l Area Pit or Grout Inspection Date Final Inspection by /r.ld - Date d-n0 Additional Comments: - W /v m m c� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 `T Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 IFEEO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ..EH1&241REV.t/95i �O O• O® EJ5 lO �.� �,_Cf� �l •..� i -EH 14-26 - C1