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rn �OA to APPLICATION FOR PERMIT ii SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA r, Telephone (209) 466-6781 ,I - i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ii iComplete 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 0- 0 J c, t f��L� Gr4�(ic.'Cf�D%�;Q1+�.'• rj*'{'F�G�'�'flt� Job Address 1030 �� pr- q,50'of� S�D_cT pr- City Lot size M P 2 r- PM 5L$pAc l.l�NB Owner's Name Address 6T G�Vn - Phone �q BJ FJaoL_ q Contractor Address License No. Phone_ ` TYPE OF WELLJPUMP: !I NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION �( PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ �f + DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I4 ❑ Industrial ,0pen.Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Welf Casing v 4 ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_-,t;!_ Specifications M Public 1-1 Other 17 Delta Depth of Grout Seal Tye of Gro t _ ItsligationJIV�!'I.Approx. Depth l I Eastern Surface Seal Installed by t - - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50 Depth Filler Material {Below 50') - I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is i n available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: I Number of bedrooms } Character of soil to a depth of 3 feet: Water table depth b r s SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ; t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I h LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well 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, and rules and regulations of the San Joaquin Local Health Di§lrict. 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." II The applicant. us c 11 ar II a fired inspections. Complete drawing on reverse side. A4- 'A, �y Signed X Title: _ 1 -� 11 ' Date: II` FOR DEPARTMENT USE ONLY l Application Accepted by Date / Area I' 7 z7_ I Pit or Grout Inspection by Dat AM9 Final Inspection by Date :i 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, Stk., CA 95201 li I, FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT•NO. INFO ,g� ♦ EH 13-24(REV.I 115) K�� e— EH 1626 r 0