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s t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISS ED r} 1r (Complete, n Triplicate) Applicatiolnniis 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. Cit •_,�/,...� Lot Size �r�/t PM �� Y Job Address � Owner's Name Jim Gy``Address Z I /4 ALr _ Phone "6¢2 Contractor Address A�4License No. ��bl�"� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ =-PUMP INSTALLATION-❑ - - ';SYSTEM-REPAIR,0-_-_-_OTHER ❑ � e I DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS r y'D INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .Type of Casing Specifications f'1 Public ; ❑ Other ❑ Delta Depth of Grout Seal'" Type of Grout 1.1 Irrigation W_.Approx. Depth 1.1 Eastern Surface Seal Installed by 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 REPAIR/ADDITION 1.1 DESTRUCTION i I (No septic system permitted if public sewer is }t available within 200 feet.) Installationiwill serve: Res Commercial Commercial Other Number of'jiving units: Number of he ms Character of soil to a depth of 3 feet: 4 Water table depth R t , SEPTIC TANK_;^ ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest, W I` Foundation „ ` Property Line G� 1 LEACHING LINE ❑ No. & Length of lines —`t7 Y Y t Total length/size HLTER BED ❑ Distance to nearest: Well Foundation Property Line } E 4 ¢ t SEEPAGE PITS ( I Depth t Size _ Number j SUMPS i ❑ Distance to nearest:--Well` '-Foundation E ",,,Property Line tq 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. "" t 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 alifornia." 1 ' ' i N, The app t ust tali for ah fired inspections. Complete drawing on rse side. , Signed Title: Date: } FOR DEPARTMENT USE ONLY Application Accepted by 4.4_tl� ! Date Area Pit or Grout Inspection by l Date. Final Inspection by Date Additional Coents:Jn —r- ❑ Stk 466-6781 i ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all4bopies tot Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 s'. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO CASH i Yit * EH11 3-24,�IREV.iirs� / .V 7U CJo d�`f�'� - 9q- Ell