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APPLICATION FOR PERMIT �( SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I. E'AR'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 i Local Health District. i f�000��RNo . Q�.Kzo Job AddressS. � 3 / _ City Lot Size PM LV HAYAt 10614iV cL Owner's Name/1O GR� ��'�p �� Add-,,,ss ' `T o��Fl ��C� Phone 3� ��a Contr ctorR��r 7.4J? �y,�r dress -?1.idD Wi CdoJS �oR� G$�/� License No. Phone TYPE OF WELL/PUMP: NEW WELL WELCREPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �� SYSTEM REPAIR ❑ OTHERj❑ DISTANCE TO NEAREST: SEPTIC TANK F '' '� SEWER LINES' DISPOSAL FLD. IRT PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r ❑ Industrial ❑ Open;Sottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casingg Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications EDPublic C1 Other i 1-1Delta Depth of Grout Seal 45710 r „r Ty of Grout 0— 0A/T L1`• ❑ Irrigation 4�Approx. Dep# ❑ Eastern,,, Sqrjece Seal Installed by AJOCOAJJAI .f qr--J? 4�JrOJJ Q Repair Work Done ❑ Type of Pump NY, P. Stale Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 r Depth_ Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION CJ -DESTRUCTION ❑ (No septic system permitted if 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 I PKG. TREATMENT PLT. F-1" Method of Disposal ` ` Distance to nearest: Well Foundation Property tine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ ,.Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 the work for which this permit is issued, I shall not i 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:;!l 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 applican s a fo all req ions. Complete drawing on re arse side. Signed X /�' y Title:2749 ate: FORJDEPAR MENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 4&6-6781 ❑ 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY + DATE PERMIT'NO. EH 13-24[REV.i/e 51 � 5 9 ` EH 1428