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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON,AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :I (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. _ Job Address G ew 0 City L O�I Lot Size PM Owner's Name 61 e w L Address I0 45 S, G e ro lse e Phone q�a(a— 857 Contractor's Name k)It IIVIIR( r[GiLST b 4y56• License No. Pi:9X1 �_VAels! 6/`>-v ,q Phone TYPE OF WELL/PUMP: i` NEW WELL.9 7 WELL REPLACEMENT ❑ DESTRUCTION FI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP}}TIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE FO NDNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TOPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zig ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing P VC _ Specifications ❑ Public �❑D�Other ❑ Delta Depth of Grout Seal ✓?� Type of Grout LPrled' ` ❑ Irrigation CLApprox. Depth ❑ Eastern Surface Seal Installed by r� Repair Work Done ❑ Type of Pump H.P. State Werk/pone El Destruction Well Diameter 0 Sealing Material (top 501 �11i?/r4Y�/r 'fir Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: M Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Il Method of Disposal Distance to nearest: Well Foundation Property Line it LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ DMistance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ °Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .11. 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 regulatiorIt-of the Sari 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 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 applican must call for all r!� 'e �arf Complete drawing on reverse side. 1 Signed Title: `- �e�� Date: l 3 FOR DEPARTMENT USE'ONLY Application Accepted byi - - Date �/ Ares 1'T/Z� Pit rout Inspection b I � ta Final Inspection by pate��eAu Additional Comments: f �f ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ Manteca -7104 ❑ Tracy 835-6YS5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /NFU AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. + EH 1324(REV.10!831 1 3 9 IG' C:!�- EH 1428 .;� 11 - / s+