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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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. GLX -P1 City, Lot Size �X PM Job Address 7 Owner's Name Address z-z Z f Phone ContractorAddress � License No.3�LZ Phone Y 'BIOS TYPE OF WELL7PUMPi --NEW WELL-❑ -- - WELL REPLACEMENT ❑ _ DESTRUCTION .❑ e,_,.,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ L DISTANCE TO NEAREST:'SEPTI,C.TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ µ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R ❑ Industrial ❑ Open Bottom ❑ Manteca,.- Dia. of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C-1 Public F l Other F1 Delta - _ -Depth of Grout-Seal Type of Grout _ I I I Irrigation =-Approx. Depth l I Eastern Surface Seal.Installed-by ° � _ I Repair Work Done ❑ 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 I)(f, REPAIR/ADDITION LI DESTRUCTION l I INo septic system permitted it public sewer is E a available within 200 feet.)„ Installation will serve: Residence A °Commercial_ Other r Number of living units: __L_ Number of bedrooms 3 Character of soil to a depth of 3 feet: b � Water table depth S© SEPTIC TANK' COY Type/Mfg Capacity /o�0lO No. Compartments PKG.'..TREATMENT PLT. ❑ ! i / Method of Disposal Distance to,nearest: Well Foundation 1 Q Property.Line .5 LEACHING LINE G'f4 No. & Length of lines �✓ �� ' Total length/size FILTER BED ❑ Distance to nearest: Well 5.0 l0 I Foundation r Property Line V 3 SEEPAGE PITS l Depth Z 5 r Size Number SUMPS" Ll Distance to nearest: Well 100 Foundation lb t Property Line S1 DISPOSAL PONDS ❑ -- -—.1 hereby certify-that-l-have-prepared-thi"ppiication-and that the-work-will-he 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 o'r 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 must call for all required ins tions. Complete drawing on reverse side.01 f Signed TiNe: Date: FOR DEPARTMENT USE ONLY i C i, Application Accepted by '� fl�y //C�^--'C!�r Date J Area Pit or Grout Inspection by "" "Date I inal Inspection by�~ Date -�'( Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECC INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. r. ♦.EH 1 -24(RW1/A 55 / j �/I _1 0} f EH 1 44-28 tires :