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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA �/} Telephone {209) 466-6781 PERMIT EXPIRES TYEAR 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City !`/t/ Lot Size S 3 6 4) PM Owner's Name -y, CJ 1 Z Z Address AWL- .4616— Phone J � Contractor /GCJLG/P Address License No. Phone WELL REPLACEMENT 71DESTRUCTION ❑ PE OF WELL/PUMP: NEW WELL ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES TANK: SEWER .LINES DISPOSAL FLD. R —00EFOUNDATION AGRICULTURE WELL OTH PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONS N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. o xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing 4 Specifications f`l Public r �❑ Delta Depth of Grout Seal Type of Grout I I Irrigation .___Approx. Depth I I Eastern Surface Seal Installed by l Repair ork Done 0 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 I 1 REPAIR/ADDITION I I DESTRUCTION {No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other 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 Distance to nearest: Well Foundation Property Line E LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation property Line SEEPAGE PITS l 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line A �"� ► DISPOSAL PONOS ❑ l 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 DiMrict. - 5 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 fof which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must must call for all re uired inspections. Complete drawing on reverse side. Signed X J �.-__ Title: f Date: 6Az !l FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date f7/6 4-1 Additional Comments: Z�a� ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 E Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201FEE { INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED By DATE F5r4 -1, ;gg-1 RMIT'NO. +.EH 13-24(REV.rirt5r s�/L r EH f4-26 Q O