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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. GQ� Job Address t �� r p p �f nG"1 C..N� City �G n Lot Size PM ! _ A !f Owner's Name —I"7 Q!`G Gl$,5 Pr p GlI G� /Address �G 'Q� _ Phone Contractor .. r Address License No. Phone TYPE'OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT ❑ DESTRUCTION ❑ _... r. . —PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ = OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! -INTENDED USE-- TYPE OF WELL—, --*`PROBLEM AREA- CONSTRUCTION SPECIFICATIONS F ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications r'1 Public f] Other ❑ Delta Depth of Grout Seat Type of Grout I 1 Irrigation ._.-_._Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done._ Well Destruction ❑ Weil Diameter Seating Materiai_(top 501- - ` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION;l DESTRUCTION l I INo septic.system permitted if public sewer is t/ available within 200 feet.) 1/ _ Installation.wilkserve:_Residence�=- Commercial -Other erg:' _- x Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: VOCC tN - -Water table depth 'i SEPTIC TANK ❑' Type/Mfg's Capacity No. Compartments I PKG. TREATMENT PLT. ❑ _ ' Method of Disposal x -distance to nearest: Well Foundation Property Line } r LEACHING LINE VNo. & Length of lines L4 6 Total length/size i FILTER BED ❑ 'Distance:to nearest: Well S704— Foundation _ Property Line SEEPAGE PITS I I Depth f s_Size y Number SUMPS Distance to-nearest: Weil". -- Foundation _Q Property Line — ,1CV DISPOSAL PONDS ❑ Q ` 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, anc4 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 no 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." ' t The applicant must call f r all requir inspections. Complete drawing on reverse side. Signed X Title: �rt Date: _44 qh F ti ; FO DEPARTMENT USE ONLY Application Accepted by Date- �e.�- Area Pit or Grout Inspection by Date Final Inspection by � Date E Additional Comments: ❑ Stk 466-6781. ' ❑ Lodi 369.3621 ❑ Manteca .623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'tUO. INFO CASH t +.EH 1324 I REV.>/14 51 S9 -1142 EH 14-2e t