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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 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. �/�y J! r { y ICJ J r Yt o�1 City G Job Address -- I Il oyti Lot Size J_ PM Owner's Name G W S Address Cd rr71 �'`O rU V Phone ��e7`7 ff6 Contractor ter Address 60 16DX 14 S License No,a, o&l Phone_ y� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER -- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P. State Work Done _ Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth A – Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I ) INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial—_ Other Number of living units: _L_ Number of bedrooms Character of soil to a depth of 3 feet: At�n i Water table depth SEPTIC TANK Xld Type/Mfg 0,:_;F7 1 C04C Co–� Capacity 1015 No. Compartments PKG. TREATMENT PLT. ❑ r r Method of Dispgsal Distance to nearest: Well 100 Foundation _ Property Line '7S" LEACHING LINE No. & Length of lines T$tal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS j I Depth 4 Size Nrmber SUMPS jel-'Distance to nearest: Well fir— 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, a 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must callforall req�reddinspections. Complete drawing on reverse side. �! Signed X Axl&- Title: p45ytlLJ Date: b FOR DEPARTMENT USE ONLY p� Application Accepted by Date "7! Area Jr, 9 Pit or Grout Inspection by Date Final Inspection by L- Date ! �� Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED lay DATE PERMIT NO. INFO CASH t.EH1 3-241REV,I/H5) EH 14-2a s