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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA !, Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 a Local Health District. r ,,, I nd Regulations of the San Joaquin Job Address _ �(G�L r n/ City It Lot Size PM Owner's Name Phone t evJ9T,�. ��'3. ContractorAddress r License No-`-& ?,eir2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION JV 1eZP4Ae10'1 STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS � ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private C1 Gravel Pack ❑ Tracy 1 T Dia. of Well Casing ype of Casing ❑ Public ❑ Other Specifications ❑ Delta Depth of Grout Seal Type LJ Irrigation = _�A d 1 yP of Grout pprox. Depth ❑ Eastern Sura a Seal Installed by Repair Work Done ❑ Type of PumpH.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth � Q p Filler Material IBelow 50'1 ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is l available within 200 feet.) ` Installation will serve: Residence— Commercial_ Other s Number of livingznits: Number of bedrooms I Character ofo fo-a-depth-of-3-feet:--,-- - � SEPTIC TANK �- t Water table depth ❑ Type/Mfg r Capacity i No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well w– Foundation Pro t k perty Line LEACHING LINE ,©.!s No. & Length of lines 1 i# y sal ;,,i o Total length/size FILTER BED ❑ Distance to nearest: Well X"f i i c Foundation Property Line r # s SEEPAGE PITS ❑ :Depth" Size Number SUMPS ❑ Distance'to nearest: Well ---�� _ i ' oundation" ti Property Line DISPOSAL PONDS ❑ hereby certify that i have prepared tFiis.applicetion and that the work will be dont in.accordanae with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heaith District. Home owner or licensed agent's signature certifies the"folldwiri z employ an � g��;1•cerdfy that•irl-t�ie performance of the work for which this permit is issued, I shall not P y 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 fa?which this pbrmitws issued,I shall employ tion laws of California." P y persons subject to workman's compensa- tion The applicant III r all re i e inspections. Complete drawing on reverse I'de',/ ( s Signed �. ��'Z _ Title: Date: FOR PARTMENT LISE ONLY G Application Accepted by Date I Area C/ Pit or Grout Inspection by Date Final Inspectiin by } Date Additional Comments:. ❑ 5tk 466-6781 ❑ Lodi X9-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE .,....-»... AMOUNT OUNT DUE AMOUNT REMITTED CK r RECEIVED BY CASH, DATE ZPERIT'NO. + EH 13-24(REV.t/e51 $� 4 `yyti s EH 1428