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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. Ll& � - ,� Ci P c City Garr Job Address Lot Size 2, e PM t i ! Apl-Ifoe Owner's Name s ' Address at ,v�d i( ' �- _--.._.__C_ .1Z,�:� �+�f rr P_ Phone -_ Contractor Z44 Address_p f�.r2"�.V- ,c� [r7a l�License No qq_S Phone .7 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 PITS/SUMPS` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r_.3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �'� f Specifications ("I Public F1 Other Ll Delta Depth of Grout Seal Type f Grout L- ,'►'aAt�77 I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by t4 h _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l 1 DESTRUCTION (.1 (No septic system permitted if public sewer is > available within 200 feet.) Installation will serve: Residence Commercial 45 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Eine 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, an rules and regulations of the Sa&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 call f r all quired inspe tions. C m I drawing on reverse side. Signed / _Title: pate: FOR DEPARTMENT USE ONLY Application Accepted by ' Date Area Pit or Grout Inspection by Date Z✓ Final Inspection by 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, Stk., CA 95201 INFO AMOUNT rDUE /� AMOUNT REMITTED I C�A/SH RECEIVED BY DATE PERMIT'NO.� p +.EH 13-24(REV,1/8 5) �O r� .�C�� O �"�� It. e I 0, .� EH 14-28 J g' � If- g?:q v QQ