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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. X� Job Address Z. --% .ice AlS//: J City Lot Size //7 /`�- PM { Owner's Name Address Phones I �i .Contractor GR`© 15S' AddreS C Q , r License No-377-I Phone3 TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHEgA 00 DISTANCE TO NEAREST: SEPTIC TANK Gat SEWER LINES DISPOSAL FLD. 0-Q_ PROP. LINE 4 E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r F-1Industrial `❑ Open Bottom L1 Manteca Dia- of Well Excavation Dia. of Well Casing (� Domestic/Private 7dGravel Pack ❑ Tracy Type of Casing Specifications ❑ Public F1 Other El Delta Depth of Grout Seal _1 Z Type of Grout. I 1 Irrigation r--.Approx. Depth rrII]I Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpH.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 V, Depth Filler Material {Below 50'1 k TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION (.1 DESTRUCTION I I INo septic system permitted if public sewer is � available within 200 feet.) In allatEOY rit1 serJe�Resiaen`c Gomme-rcial "Others" Number of living units: Number of bedrooms— Character edrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line k LEACHING LINE ElNo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line I SEEPAGE PITS I I Depth --Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i '. DISPOSAL PONDS Cl 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, an&b1ZJ 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 II for all req 'ed inspections. Complete drawing on reverse side. X _ Title; C94� 6—n� -2- _ Date: Signed - FOR DEPARTMENT USE ONLY �! Application Accepted by� 390Date _` /� g g Area�/1 Pit or Grout Inspectiori by Date Final inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE jPERIMIT'NJO.INFO I+ EH 13-24 IRfV.t/H 51 Ass7 l.S +� l / 1 f' EH t4-26