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sin _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q P Ot t I 1601 E. HAZE T ON AVE., STOCKTON, CA - Telephone [2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �P+ {Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herfn desVrfbRed This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address r05�) -� -A a'c,._ � ��ed� City Lot Size PM Owner's Name �lrt (�(/�iC�t4.!1 /lAddress [t�� 7 /Gcsr G�r PhoneT &00'0 Contractor G � 64-`1 Address ��d (/ �� , �� license No. Sr�h/y, Phone(�/- 7r� TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT L1 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 71-5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION N Z&/ AGRICULTURE WELL OTHER WELL PITS/SUMPS N fs/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d ❑ Industrial FA ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing — Specifications Cl Public ❑ Other n Delta Depth of Grout Seal N W r Type of Grout er Cp> . t I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by 1W rpt 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 11 REPAIR/ADDITION ( I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) installation will serve: Residence_ Commercial_ Other i Number of living units: 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. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line V f LEACHING LINE ❑ No. & Length of lines Total length/size 'TI FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS L1 Distance'to nearest: 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thework 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,1 shall employ persons subject to workman's compensa- tion laws of California—" The applicantmust II for all req ire 'spec ions. Complete drawing on reve�rAe s�id�e. ✓� �, p Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by , _ Date�� 12- y Area Pit or Grout Inspection by _ ^Ff�f r Date .L�__._ .--_ Final Inspection by Date Additional Comments: j- ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMIT-TED CASH ED Cr INFO RECEIVED BY DATE PERMIT NO. F a EH 13.24{REV_i i n 51 / EH 14-26