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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,STOCKTON, CA "Telephone '{209) 466-6781 IPERMITEXPIRE's-l 'iE�4R''FROM'D'A'T'E 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. - Job Address � c' c%�.p/j / City S Lot Size PM Owner's Name !e /' ' d GCC Address Q w Phone 30 Contractor l e[ Address License No. Phone TYPE OF WELL/PUMP: ;NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 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 O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other L ,❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx.'Depth +.❑ Eastern C Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P:, State Work Done_ 3 Well Oestruction ❑ Well Diameter's x Sealing Material (top 50'):. Depth4' Filler Material (Below 50') �/} j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION Ll DESTRUCTION (No septic system permitted if public sewer is 00 available within 200 feet.I �.. Installation will serve: Residence Commercial Other Number of living units: Number f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg p I.Capacity No. Compartments PKG. TREATMENT PLT. ❑ I f Method of Disposal,` 'r Distance to nearest: Well Foundation Property Line ,LEACHING LINE Cl No. & Leng aflines : Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line l .a SEEPAGE PITS ❑ Depth Size Number ` SUMPS ❑ Distance to nearest: Foudatio" " nPo17 DISPOSAL PONDS ❑ - t , 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 i rules and regulations of the San Joaquin!Local Health District. j Homeowner or,licensed agent's signatur6-certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall notes 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: ".1 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 mast calf for all re uired inspectio s. Complete drawing on reverse side" I Signed v Title:. Llh.4/t Date: FOR DEPARTMENT USE ONLY _ Application Accepted by Date � y Area I Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 4W-6781 ff Lodi 3R4 621, ❑ Ma tern 1323-7104 .❑ Tracy 835-6355 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 CK RECEIVED BY DATE PERMIYNO. + EH13-24(REV.i/R5) EH 14-28 11