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APPLI.CATION,FOR PERMIT )w C! SAN JOAO,UIN,LOCAL HEALTH DISTRICT_ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone•(209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,. ., _. :: _ (Complete]n :Triplicate} .,k„ 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 Bounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 01,44 4,61 Job AddressRX" 4 -�4;v '5City �� Lot Size J/,Z.._ PM Owner's NametJ GCI�� Address Phone ---- _ 0 'Contractor f LG[ Address . License No a Phone TYPE OF WELL/PUMP: KNEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑.. ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ` Dia. of Well Excavation Dia. of Wel Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _1 P\Type of'Casin r Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout '1v0-Irrigation--- __4pprox:-•Depth---❑'Eastern` Surfade'Seal'In`s'talled by" Repair Work OoneEl Type of Pump H.P. State Work Done Ih Well Destruction 13 Well Diameter Sealing Nlateriallftop 501 Depth i Filler Material {Below 501 TYPE OF..SEPTIC WORK: NEW INSTALLATION REPAIR/ADDIIiION'❑ DESTRUCTION ❑ (No septic system permitted it public sewer is available,within 200 feet.l' - Installation will serve: Residence Commercial_` Other h Number of living units: Number of bedrooms, Character of soil to a depth of 3 feet: Water table depth r G ` SEPTIC TANK 1-1:-Type/Mfg 31 t i /capacitya2o�Vx3T_ No. Compartments PKG. TREATMENT PLT ❑ j I I � � r` � � I � � Method of Disposal -f `Distance-ttb nearest: Well Foundation_a ;y - Property Line �F4t LEACHING LINE ❑ !"No. & Length of lines I�T,o�tal length/size C� i FILTER BED ❑ 'bistanceh to nearest: Well I Foundation�r� PrO er[y:Liile � k ti SEEPAGE'PITS ❑ Depth Size Number SUMPS 17 Distancetonearest: ,. Well Foundation- Property Line 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.. ' y': 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 emply any person in such manner as to become subject to workman's compensa' 'idn laws-oMilkornia:'`Cortractor's hiring or sub-contracting signature certifies the following: "t certify that in the performance ofthe work for which this permit is issued I shall employ parsons subject to workman's compensa- tion tion laws of California." II fir, The applicant must,call for all squire llinspections. Complete drawino on rave sa side.I Ji i Signed.X Title M i Date: x � I e FOR DEPARTMtNT USE ONLY Application Accepted by f Date ` Area 1 ` Pit or Gfout Inspection by X Date Final lrispection b 'Date Additional Comments: r i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -823-7104 - t ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health;Permit/Services 1601 E. Hazelton Ave., P.O: fox 2003, Stk., CA 95201 F R1. FEE NFO AMOUNT.-DUES ._..AMOUNT REMITTED CK —-RECEIVED-Bye ��-DATE�=j -PERIVIIT•N&— I .trAS EH 13-24(REV.1/rs5) ' G� , ''/7, u 71 ' EH 14-29 ��