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IAm APPLICATION FOR PERMIT `�� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address lef City Lot Size PM Owner's Name _I ,yl Address �� GrlJ, �t Phone dWTi6la- a Contractor !"o Address ` License No. f Phone TYPE OF WELL/PUMP: w NEW WELLeW, WELL REPLACEMENT 1-1-4- DESTRUCTION ❑ PUMP INSTALL47ION,;? SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� f DISPOSAL FLO. PROP. LINE !O! FOUNDATION AGRICULTURE WELL �- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ Open Bottom ❑ Manteca a Dia. of Well Excavation ZOODia. of Well Casing ADomestic/Private ,WGravel Pack ❑ Tracy Type of using Specifications _56L__ 11 Public �❑1 Other [1 Delta Depth of Grout Seal Type pf Grout C I I Irrigation -Approx. Depth { I Eastern Surface Seal Installed by 5 '_ Repair Work Done ❑ Type of Pump H.P, State Work Done _ 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler,Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is �-+ available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other Number of living units: 0 M 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. C7 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS L-] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0—,. - I .-1 hereby cert at I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and,ragulations of the San Joaquin Local Health District. Home-dwner or licensed agent's signature certifies the following: "I certify that in the performance of the iAtork 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 applica ust requi ons. Complete drawing on revers ide. g Signed X ills: Date: C] r FOR DEPARTMENT USE NLY u Application Accepted by _ Date / Area Pit or Grout Inspection by Date Final Inspection by m Date -a4 4 Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 RECEIVED BY DATE PERMIT'NO. +.EH 1321 PREY.t/x s! /I /j� EH 14-26 fff�s r +� f