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j 4 APPLICATION FOR PERMIT I t SAN JOAQUIN LOCAL HEALTH DISTRICT i P 1601 E. HAZEL T 64 AVE., STOCKTON, CA Telephone (200) 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. 7 r Job Address Lot Size PM S C f�� ' City.. Owner's'Nam /�cif' GCS r ' Address -5/1_57 Irx K-a ' Phone`' 6 y7 v Contractor Address License No. Phone TYPE OF WE /PUMP: NEW WELL ❑ WELL REPLACEMENT C7 ESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REP OTHER DISTANCE TO NEAREST: C TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA AGRIC E WELL OTHER WELL PITS/SUMPS' INTENDED USE TYPE OF WELL AREA CONSTRUCTION SPECIFICATIONS 999! ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel ❑ Tracy Type trig Specifications ❑ Public er ❑ Delta Depth of Grout a Type of Grout ❑ Irrigation i ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ¢ I 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: Number of bedrooms Chafacter of soil to a depth of 3 feet-, Water table depth SEPTIC TANK X Type/Mfi, r Capacity No. Compartments PKG. TREATMENT PLT- ❑ ° Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length yf.lines Total length/size FILTER BED ❑ Distance to.nearest: Well Foundation Property Line I y f SEEP4GEjPITS ❑ Depth Size Number SUMPS V ..D- Distance to.nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wi lWwill tie done in'sccordance 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 oompensatton laws of Cal-lfornia." Coriiractors hiring or sub-contracting signature I 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 appli ant must call for all quired inspections. Comple dr wi`g on reverse"side. 1 _ Signed itle 9 t Date: FOR DEPARTMENT USE ONLY' t - Application Accepted by milli Date -)' Area Pit or Grout Inspection Date Final Inspection by Date r k Additional Comments: ❑ Stk 466-6781 ❑ Lodi, 369-3621__ ❑ Manteca 823-7104.,x.❑,Tracy_ Applicant - Return all copies to: Environmental Health.Permit/Services 1601/E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i IFEE NFO'J,�AMOUNT DUE+ -�AMOUNT REMITTED;— CASH -'°`RECEIVED-SY— ��DATE�^ PERMIT'NO':'° + E EV - ` - Z EH 14-29 0